Provider Demographics
NPI:1275973166
Name:MERIDIAN ENDODONTICS AND PERIODONTICS
Entity Type:Organization
Organization Name:MERIDIAN ENDODONTICS AND PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:FRISBIE-TEEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-327-6100
Mailing Address - Street 1:20350 WATER TOWER BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3558
Mailing Address - Country:US
Mailing Address - Phone:262-327-6100
Mailing Address - Fax:
Practice Address - Street 1:20350 WATER TOWER BLVD STE 203
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-3558
Practice Address - Country:US
Practice Address - Phone:262-327-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65911223E0200X
WI6841.151223E0200X
WI6852.151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty