Provider Demographics
NPI:1417119710
Name:TECLAW, BRIAN R (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:TECLAW
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 1:2301 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1901
Mailing Address - Country:US
Mailing Address - Phone:414-321-2320
Mailing Address - Fax:414-321-2766
Practice Address - Street 1:2301 S 108TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1901
Practice Address - Country:US
Practice Address - Phone:414-321-2320
Practice Address - Fax:414-321-2766
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice