Provider Demographics
NPI:1801182225
Name:OBERSCHLAKE, ROSS LEWIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:LEWIS
Last Name:OBERSCHLAKE
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 1:1518 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4102
Mailing Address - Country:US
Mailing Address - Phone:920-261-8228
Mailing Address - Fax:
Practice Address - Street 1:1518 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4102
Practice Address - Country:US
Practice Address - Phone:920-261-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7251-15122300000X
IL019028681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist