Provider Demographics
NPI:1992806269
Name:PREMIER ORAL & MAXILLOFACIAL SURGERY S.C.
Entity type:Organization
Organization Name:PREMIER ORAL & MAXILLOFACIAL SURGERY S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-756-8744
Mailing Address - Street 1:1602 N RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1124
Mailing Address - Country:US
Mailing Address - Phone:608-756-8744
Mailing Address - Fax:608-756-5344
Practice Address - Street 1:1602 N RANDALL AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1124
Practice Address - Country:US
Practice Address - Phone:608-756-8744
Practice Address - Fax:608-756-5344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5E102501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI76580Medicare ID - Type Unspecified