Provider Demographics
NPI:1528241486
Name:ASSOCIATED ORAL & MAXILLOFACIAL SURGEONS SC
Entity type:Organization
Organization Name:ASSOCIATED ORAL & MAXILLOFACIAL SURGEONS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:RIESCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-253-6588
Mailing Address - Street 1:N89 W16785 APPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051
Mailing Address - Country:US
Mailing Address - Phone:262-253-6588
Mailing Address - Fax:
Practice Address - Street 1:N89 W16785 APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051
Practice Address - Country:US
Practice Address - Phone:262-253-6588
Practice Address - Fax:262-253-6893
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASSOCIATED ORAL AND MAXILLOFACIAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-13
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42871223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000079120Medicare PIN