Provider Demographics
NPI:1962416057
Name:DEZIEL, DENNIS (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:DEZIEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 80TH ST
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-5310
Mailing Address - Country:US
Mailing Address - Phone:715-472-2587
Mailing Address - Fax:
Practice Address - Street 1:900 COLLEGE AVE W
Practice Address - Street 2:
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848-2116
Practice Address - Country:US
Practice Address - Phone:715-532-5561
Practice Address - Fax:715-532-9809
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIE34451Medicare UPIN