Provider Demographics
NPI:1306950902
Name:PEREZ, CELESTINO F (DDS)
Entity type:Individual
Prefix:DR
First Name:CELESTINO
Middle Name:F
Last Name:PEREZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1285
Mailing Address - Country:US
Mailing Address - Phone:262-284-9767
Mailing Address - Fax:262-284-5228
Practice Address - Street 1:1000 N WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1285
Practice Address - Country:US
Practice Address - Phone:262-284-9767
Practice Address - Fax:262-284-5228
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33723100Medicaid