Provider Demographics
NPI:1225258254
Name:OBRIEN, JEFFREY M (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:OBRIEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W247 S3114 PRAIRIE AVENUE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189
Mailing Address - Country:US
Mailing Address - Phone:262-544-4404
Mailing Address - Fax:262-544-4399
Practice Address - Street 1:W247 S3114 PRAIRIE AVENUE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189
Practice Address - Country:US
Practice Address - Phone:262-544-4404
Practice Address - Fax:262-544-4399
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5057122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5057OtherLICENSE