| Cedar Lake Dental Professionals Ltd | |
|
145 N 18th Avenue West Bend WI 53095 | |
| (262) 334-3084 | |
| (262) 334-3552 |
| Full Name | Cedar Lake Dental Professionals Ltd |
|---|---|
| Speciality | Dentist - Prosthodontics |
| Location | 145 N 18th Avenue, West Bend, Wisconsin |
| Authorized Official Name and Position | Lysette L Brueggeman (OWNER) |
| Authorized Official Contact | 2623343084 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Cedar Lake Dental Professionals Ltd 145 N 18th Avenue West Bend WI 53095 Ph: (262) 334-3084 | Cedar Lake Dental Professionals Ltd 145 N 18th Avenue West Bend WI 53095 Ph: (262) 334-3084 |
| NPI Number | 1790840734 |
|---|---|
| Provider Enumeration Date | 12/27/2006 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1790840734 | NPI | - | NPPES |
| 33761800 | Other | WI | MEDICAID |
| 33713000 | Medicaid | WI | |
| 650286 | Other | UNITED CONCORDIA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 4368 (Wisconsin) | Primary |
| 1223P0700X | Dentist - Prosthodontics | 4408 (Wisconsin) | Primary |
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