Provider Demographics
NPI:1013020866
Name:ORAL SURGERY ASSOC LTD
Entity Type:Organization
Organization Name:ORAL SURGERY ASSOC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:K
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:920-923-0111
Mailing Address - Street 1:464 SOUTH HICKORY STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935
Mailing Address - Country:US
Mailing Address - Phone:920-923-0111
Mailing Address - Fax:920-923-0366
Practice Address - Street 1:464 SOUTH HICKORY STREET
Practice Address - Street 2:SUITE A
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-923-0111
Practice Address - Fax:920-923-0366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001856-015204E00000X
WI5000111-015204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty