# GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1205136074
- **Authorized official:** MRS. CONNIE LOUISE MILLER (PRACTICE MANAGER)
- **Authorized official phone:** (651) 351-1010

## Contact information

- **Practice address:** 227 MERIDIAN DR \# 6, NEW RICHMOND, WI 54017-2565
- **Practice address phone:** (715) 246-5150
- **Practice address fax:** (715) 246-5102
- **Mailing address:** 227 MERIDIAN DR \# 6, NEW RICHMOND, WI 54017-2565
- **Mailing address phone:** (715) 246-5150
- **Mailing address fax:** (715) 246-5102

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 4482 | WI | Yes |

## Other

- **Enumeration date:** 10/27/2010
- **Last updated:** 10/27/2010