Organization Name: | ORAL SURGERY ASSOC LTD |
NPI Number: | 1013020866 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | GUY K JENSEN (OWNER) |
Mailing Address: | 464 South Hickory Street Suite A Fond Du Lac |
State: | WI US |
Postal Code: | 54935 |
Phone Number: | 9209230111 |
Fax Number: | 9209230366 |
NPI Enumeration Date: | 08/16/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 204E00000X |
License Number: | 5001856-015 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | WI |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | Oral & Maxillofacial Surgery |
Taxonomy Specialization: | |
Taxonomy Definition: |