Provider Demographics
NPI:1023670254
Name:IVERSON, AUSTIN ALLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:ALLEN
Last Name:IVERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2043
Mailing Address - Country:US
Mailing Address - Phone:262-284-5505
Mailing Address - Fax:
Practice Address - Street 1:1349 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2043
Practice Address - Country:US
Practice Address - Phone:262-284-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002153-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist