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General NPI Number Information
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NPI Number | 1790935914
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Entity Type | Individual
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Provider Name | JERRY LEE CEILESH D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 09/24/2008
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Last Update Date | 09/24/2008
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Provider Practice Location Address
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Address Line | 21425 SPRING ST
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City | UNION GROVE
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State | WI
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Zip | 53182-9707
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Country | US
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Telephone | 262-878-2411
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Fax | 262-878-2922
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Provider Business Mailing Address
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Address Line | 21425 SPRING ST
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City | UNION GROVE
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State | WI
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Zip | 53182-9707
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Country | US
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Telephone | 262-878-2411
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Fax | 262-878-2922
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5001598-015
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License Number State | WI
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