# PREMIER ORAL & MAXILLOFACIAL SURGERY S.C.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Southern Wisconsin Oral & Maxillofacial Surgery S.C.
- **Organization subpart:** No

## Provider details

- **NPI number:** 1992806269
- **Authorized official:** CRYSTAL M DIETER (MANAGER)
- **Authorized official phone:** (608) 756-8744

## Contact information

- **Practice address:** 1602 N RANDALL AVE, JANESVILLE, WI 53545-1124
- **Practice address phone:** (608) 756-8744
- **Practice address fax:** (608) 756-5344
- **Mailing address:** 1602 N RANDALL AVE, JANESVILLE, WI 53545-1124
- **Mailing address phone:** (608) 756-8744
- **Mailing address fax:** (608) 756-5344

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 5E10250 | WI | Yes |

## Other

- **Enumeration date:** 09/26/2006
- **Last updated:** 06/11/2012