Provider Demographics
NPI:1144772906
Name:ORAL FACIAL AND PERIODONTAL SURGERY LLC
Entity Type:Organization
Organization Name:ORAL FACIAL AND PERIODONTAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:262-886-0147
Mailing Address - Street 1:5801 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406
Mailing Address - Country:US
Mailing Address - Phone:262-886-0147
Mailing Address - Fax:
Practice Address - Street 1:5801 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-886-0147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7006-151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty