Provider Demographics
NPI:1467656843
Name:FOSTER, JEFFREY ALLAN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALLAN
Last Name:FOSTER
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4226
Mailing Address - Country:US
Mailing Address - Phone:715-842-4649
Mailing Address - Fax:715-842-7331
Practice Address - Street 1:413 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4226
Practice Address - Country:US
Practice Address - Phone:715-842-4649
Practice Address - Fax:715-842-7331
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI59381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics