Healthcare Provider Details

I. General information

NPI: 1063545903
Provider Name (Legal Business Name): OOSTBURG FAMILY DENTISTRY, L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 N 4TH ST
OOSTBURG WI
53070-1250
US

IV. Provider business mailing address

19 N 4TH ST
OOSTBURG WI
53070-1250
US

V. Phone/Fax

Practice location:
  • Phone: 920-564-2925
  • Fax: 920-564-6407
Mailing address:
  • Phone: 920-564-2925
  • Fax: 920-564-6407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4012
License Number StateWI

VIII. Authorized Official

Name: WILLIAM D GUZZETTA
Title or Position: DENTIST
Credential: D.D.S.
Phone: 920-564-2925