Provider Demographics
NPI:1932550720
Name:IMERMAN, AUSTIN REID (DDS)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:REID
Last Name:IMERMAN
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 1:434 SIDNEY ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-1724
Mailing Address - Country:US
Mailing Address - Phone:641-757-1099
Mailing Address - Fax:
Practice Address - Street 1:880 14TH ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1540
Practice Address - Country:US
Practice Address - Phone:608-356-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001360 - 15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist