Provider Demographics
NPI:1942523436
Name:TANNLEGER AS ORAL AND MAXILLOFACIAL SURGERY SC
Entity Type:Organization
Organization Name:TANNLEGER AS ORAL AND MAXILLOFACIAL SURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:GUTTU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-362-9391
Mailing Address - Street 1:2359 MURPHY WOODS RD
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2343
Mailing Address - Country:US
Mailing Address - Phone:608-362-9391
Mailing Address - Fax:608-362-8020
Practice Address - Street 1:2359 MURPHY WOODS RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2343
Practice Address - Country:US
Practice Address - Phone:608-362-9391
Practice Address - Fax:608-362-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty