Basic Information
| Provider Information | |||||||||
| NPI: | 1023186129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TETEAK | ||||||||
| FirstName: | MYLES | ||||||||
| MiddleName: | DENNIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 476 WATER ST | ||||||||
| Address2: | P.O. BOX 126 | ||||||||
| City: | PRAIRIE DU SAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535781127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086433855 | ||||||||
| FaxNumber: | 6086436295 | ||||||||
| Practice Location | |||||||||
| Address1: | 476 WATER ST | ||||||||
| Address2: | |||||||||
| City: | PRAIRIE DU SAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535781127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086433855 | ||||||||
| FaxNumber: | 6086436295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 4611-015 | WI | Y | Dental Providers | Dentist | General Practice |
No ID Information.