Healthcare Provider Details

I. General information

NPI: 1396685491
Provider Name (Legal Business Name): SAMUEL BEHREND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 OLD SCHOOLHOUSE ROAD
OCONOMOWOC WI
53066
US

IV. Provider business mailing address

1672 OLD SCHOOLHOUSE ROAD
OCONOMOWOC WI
53066
US

V. Phone/Fax

Practice location:
  • Phone: 262-244-5220
  • Fax:
Mailing address:
  • Phone: 262-244-5220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6002130-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: