Provider Demographics
NPI:1366505224
Name:PESCH, JOHN F JR (OR)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:F
Last Name:PESCH
Suffix:JR
Gender:M
Credentials:OR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:536 MAIN ST
Mailing Address - City:BROWNSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53006-0068
Mailing Address - Country:US
Mailing Address - Phone:920-583-3454
Mailing Address - Fax:920-583-3459
Practice Address - Street 1:536 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53006-0068
Practice Address - Country:US
Practice Address - Phone:920-583-3454
Practice Address - Fax:920-583-3459
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50013921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33613200OtherMEDICAL ASSISTANCE