Provider Demographics
NPI:1790935914
Name:CEILESH, JERRY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:CEILESH
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 1:21425 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-9707
Mailing Address - Country:US
Mailing Address - Phone:262-878-2411
Mailing Address - Fax:262-878-2922
Practice Address - Street 1:21425 SPRING ST
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-9707
Practice Address - Country:US
Practice Address - Phone:262-878-2411
Practice Address - Fax:262-878-2922
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001598-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist