Provider Demographics
NPI:1477647832
Name:ORAL SURGERY ASSOCIATES OF MILWAUKEE SC
Entity Type:Organization
Organization Name:ORAL SURGERY ASSOCIATES OF MILWAUKEE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KORTEBEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-241-0900
Mailing Address - Street 1:10535 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5583
Mailing Address - Country:US
Mailing Address - Phone:262-241-0900
Mailing Address - Fax:262-241-0904
Practice Address - Street 1:10535 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5583
Practice Address - Country:US
Practice Address - Phone:262-241-0900
Practice Address - Fax:262-241-0904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4130-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty