Provider Demographics
NPI:1790840734
Name:CEDAR LAKE DENTAL PROFESSIONALS LTD
Entity Type:Organization
Organization Name:CEDAR LAKE DENTAL PROFESSIONALS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYSETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRUEGGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-334-3084
Mailing Address - Street 1:145 N 18TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095
Mailing Address - Country:US
Mailing Address - Phone:262-334-3084
Mailing Address - Fax:262-334-3552
Practice Address - Street 1:145 N 18TH AVENUE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095
Practice Address - Country:US
Practice Address - Phone:262-334-3084
Practice Address - Fax:262-334-3552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43681223G0001X
WI44081223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33761800OtherMEDICAID
WI33713000Medicaid
650286OtherUNITED CONCORDIA