Provider Demographics
NPI:1619042686
Name:JAKUSZ, BRIAN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:R
Last Name:JAKUSZ
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:N95W25901 CTY HWY Q
Mailing Address - Street 2:SUITE I
Mailing Address - City:COLGATE
Mailing Address - State:WI
Mailing Address - Zip Code:53017-9225
Mailing Address - Country:US
Mailing Address - Phone:262-628-0555
Mailing Address - Fax:
Practice Address - Street 1:N95W25901 CTY HWY Q
Practice Address - Street 2:SUITE I
Practice Address - City:COLGATE
Practice Address - State:WI
Practice Address - Zip Code:53017-9225
Practice Address - Country:US
Practice Address - Phone:262-628-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5492015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33793900Medicaid