Basic Information
Provider Information | |||||||||
NPI: | 1376896571 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZACHARIAS | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RDH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SCHERBERT | ||||||||
OtherFirstName: | JAMIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RDH | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 880 HERRIOT DR | ||||||||
Address2: |   | ||||||||
City: | MAUSTON | ||||||||
State: | WI | ||||||||
PostalCode: | 539482031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088476700 | ||||||||
FaxNumber: | 6088476122 | ||||||||
Practice Location | |||||||||
Address1: | 880 HERRIOT DR | ||||||||
Address2: |   | ||||||||
City: | MAUSTON | ||||||||
State: | WI | ||||||||
PostalCode: | 539482031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088476700 | ||||||||
FaxNumber: | 6088476122 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2012 | ||||||||
LastUpdateDate: | 10/25/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 10639016 | WI | Y |   | Dental Providers | Dental Hygienist |   |
No ID Information.