Provider Demographics
NPI:1174604888
Name:DOUGLAS PERSICH, DDS
Entity type:Organization
Organization Name:DOUGLAS PERSICH, DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:PERSICH
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-258-2500
Mailing Address - Street 1:7130 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4708
Mailing Address - Country:US
Mailing Address - Phone:414-258-2500
Mailing Address - Fax:414-238-6881
Practice Address - Street 1:7130 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4708
Practice Address - Country:US
Practice Address - Phone:414-258-2500
Practice Address - Fax:414-238-6881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50016441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38357100Medicaid