Healthcare Provider Details

I. General information

NPI: 1679132815
Provider Name (Legal Business Name): WISCONSIN ORAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 W LINCOLN AVE STE 101
WEST ALLIS WI
53227-1255
US

IV. Provider business mailing address

401 EDGEWATER PL STE 430
WAKEFIELD MA
01880-6225
US

V. Phone/Fax

Practice location:
  • Phone: 414-327-4130
  • Fax:
Mailing address:
  • Phone: 781-213-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT TRETTIN
Title or Position: PRESIDENT
Credential: DDS
Phone: 414-357-2040