Provider Demographics
NPI:1023186129
Name:TETEAK, MYLES DENNIS (DDS)
Entity type:Individual
Prefix:DR
First Name:MYLES
Middle Name:DENNIS
Last Name:TETEAK
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 1:476 WATER ST
Mailing Address - Street 2:P.O. BOX 126
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-1127
Mailing Address - Country:US
Mailing Address - Phone:608-643-3855
Mailing Address - Fax:608-643-6295
Practice Address - Street 1:476 WATER ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1127
Practice Address - Country:US
Practice Address - Phone:608-643-3855
Practice Address - Fax:608-643-6295
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4611-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice