Provider Demographics
NPI:1477065787
Name:CENTRAL WISCONSIN ORAL AND FACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:CENTRAL WISCONSIN ORAL AND FACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-525-0900
Mailing Address - Street 1:968 RIBAUT RD STE 3
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-8002
Mailing Address - Country:US
Mailing Address - Phone:843-525-0900
Mailing Address - Fax:843-525-0380
Practice Address - Street 1:438 EDISON ST
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-1845
Practice Address - Country:US
Practice Address - Phone:715-432-4565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5831-151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty