Healthcare Provider Details

I. General information

NPI: 1841295599
Provider Name (Legal Business Name): GEORGE G HARTL DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 CHESTNUT ST
WEST BEND WI
53095-3007
US

IV. Provider business mailing address

1305 CHESTNUT ST
WEST BEND WI
53095-3007
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-2361
  • Fax: 262-334-1664
Mailing address:
  • Phone: 262-334-2361
  • Fax: 262-334-1664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3483-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: