Provider Demographics
NPI:1275667149
Name:ORTHODONTIC SPECIALISTS OF MADISON
Entity Type:Organization
Organization Name:ORTHODONTIC SPECIALISTS OF MADISON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:608-664-9500
Mailing Address - Street 1:202 S GAMMON RD
Mailing Address - Street 2:STE. 150
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1400
Mailing Address - Country:US
Mailing Address - Phone:608-664-9500
Mailing Address - Fax:608-664-9566
Practice Address - Street 1:202 S GAMMON RD
Practice Address - Street 2:STE. 150
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1400
Practice Address - Country:US
Practice Address - Phone:608-664-9500
Practice Address - Fax:608-664-9566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3613-0151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty