Provider Demographics
NPI:1225556160
Name:MILWAUKEE DENTAL ARTS LLC
Entity Type:Organization
Organization Name:MILWAUKEE DENTAL ARTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:FERRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-490-5802
Mailing Address - Street 1:20 SUTPHIN ST APT 305
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2622
Mailing Address - Country:US
Mailing Address - Phone:262-490-5802
Mailing Address - Fax:
Practice Address - Street 1:2700 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-2455
Practice Address - Country:US
Practice Address - Phone:262-490-5802
Practice Address - Fax:262-490-5802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental