Healthcare Provider Details

I. General information

NPI: 1205136074
Provider Name (Legal Business Name): GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 MERIDIAN DR # 6
NEW RICHMOND WI
54017-2565
US

IV. Provider business mailing address

227 MERIDIAN DR # 6
NEW RICHMOND WI
54017-2565
US

V. Phone/Fax

Practice location:
  • Phone: 715-246-5150
  • Fax: 715-246-5102
Mailing address:
  • Phone: 715-246-5150
  • Fax: 715-246-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4482
License Number StateWI

VIII. Authorized Official

Name: MRS. CONNIE LOUISE MILLER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 651-351-1010