Provider Demographics
NPI:1063420206
Name:LAKE GENEVA ORAL AND MAXILLOFACIAL SURGERY, LTD
Entity type:Organization
Organization Name:LAKE GENEVA ORAL AND MAXILLOFACIAL SURGERY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:OZMENT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-248-8766
Mailing Address - Street 1:312 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-1904
Mailing Address - Country:US
Mailing Address - Phone:262-248-8766
Mailing Address - Fax:262-248-6790
Practice Address - Street 1:312 CENTER ST
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-1904
Practice Address - Country:US
Practice Address - Phone:262-248-8766
Practice Address - Fax:262-248-6790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI76484Medicare ID - Type Unspecified