Provider Demographics
NPI:1679132815
Name:WISCONSIN ORAL SURGERY LLC
Entity Type:Organization
Organization Name:WISCONSIN ORAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TRETTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-357-2040
Mailing Address - Street 1:401 EDGEWATER PL STE 430
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-6225
Mailing Address - Country:US
Mailing Address - Phone:781-213-0240
Mailing Address - Fax:
Practice Address - Street 1:10401 W LINCOLN AVE STE 101
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1255
Practice Address - Country:US
Practice Address - Phone:414-327-4130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DENTAL SPECIALISTS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty