Basic Information
Provider Information
NPI: 1235167727
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MYERS
FirstName: DANIEL
MiddleName: EDMOND
NamePrefix: DR.
NameSuffix:  
Credential: D.D.S
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3113 FLEUR DE LIS DR
Address2:  
City: MEQUON
State: WI
PostalCode: 530922302
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 347 PARK AVE
Address2:  
City: PEWAUKEE
State: WI
PostalCode: 530723413
CountryCode: US
TelephoneNumber: 2626911000
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/30/2006
LastUpdateDate: 03/18/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X5101-015WIY Dental ProvidersDentist 

ID Information
IDTypeStateIssuerDescription
3375370005WI MEDICAID


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