Healthcare Provider Details

I. General information

NPI: 1790840734
Provider Name (Legal Business Name): CEDAR LAKE DENTAL PROFESSIONALS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 N 18TH AVENUE
WEST BEND WI
53095
US

IV. Provider business mailing address

145 N 18TH AVENUE
WEST BEND WI
53095
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-3084
  • Fax: 262-334-3552
Mailing address:
  • Phone: 262-334-3084
  • Fax: 262-334-3552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4368
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4408
License Number StateWI

VIII. Authorized Official

Name: DR. LYSETTE L BRUEGGEMAN
Title or Position: OWNER
Credential: DDS
Phone: 262-334-3084