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General NPI Number Information
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NPI Number | 1174604888
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Entity Type | Organization
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Legal Business Name | DOUGLAS PERSICH, DDS
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7130 W GREENFIELD AVE
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City | WEST ALLIS
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State | WI
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Zip | 53214-4708
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Country | US
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Telephone | 414-258-2500
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Fax | 414-238-6881
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Provider Business Mailing Address
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Address Line | 7130 W GREENFIELD AVE
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City | WEST ALLIS
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State | WI
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Zip | 53214-4708
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Country | US
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Telephone | 414-258-2500
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Fax | 414-238-6881
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Authorized Official
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Title or Position | OWNER
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Name | DR. DOUGLAS J PERSICH II
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Credential | DDS
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Telephone | 414-258-2500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5001644
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License Number State | WI
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