Healthcare Provider Details

I. General information

NPI: 1811086135
Provider Name (Legal Business Name): BRETT R OLM DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 AIRPORT DR
ONEIDA WI
54155-9035
US

IV. Provider business mailing address

548 REDBIRD CIR
DE PERE WI
54115-8785
US

V. Phone/Fax

Practice location:
  • Phone: 920-869-2711
  • Fax:
Mailing address:
  • Phone: 920-964-0144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4923-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: