Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 5000496 | WI |
NPI | 1093789331 |
---|---|
Provider Name | Dr. Fredrick C Austermann |
First Address | Cudahy, WI 53110-3096 |
Second Address | Cudahy, WI 53110-3096 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2006 |
Last Update Date | 06/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
33535800 | (05) | WI |