Provider Demographics
NPI:1417049743
Name:RIESCH, TERRENCE JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:JOHN
Last Name:RIESCH
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:N89W16785 APPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2071
Mailing Address - Country:US
Mailing Address - Phone:262-253-6588
Mailing Address - Fax:262-253-6893
Practice Address - Street 1:N89W16785 APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2071
Practice Address - Country:US
Practice Address - Phone:262-253-6588
Practice Address - Fax:262-253-6893
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU61115Medicare UPIN