Provider Demographics
NPI:1285649921
Name:ORAL & MAXILLOFACIAL SURGERY CONSULTANTS OF WISCONSIN, S.C.
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY CONSULTANTS OF WISCONSIN, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:NELLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-281-3344
Mailing Address - Street 1:4811 S 76TH ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4364
Mailing Address - Country:US
Mailing Address - Phone:414-281-3344
Mailing Address - Fax:414-281-1080
Practice Address - Street 1:4811 S 76TH ST
Practice Address - Street 2:SUITE 304
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4364
Practice Address - Country:US
Practice Address - Phone:414-281-3344
Practice Address - Fax:414-281-1080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT62850Medicare UPIN
WI79402Medicare ID - Type UnspecifiedPROVIDER ID NUMBER