Active NPI
Brian R Jakusz, DDS
- Dentist
- Colgate, WI
National Provider Identifier
1619042686
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 5492015
- Practice address
- N95W25901 Cty Hwy Q
Suite I
Colgate, WI 53017-9225 - Phone
- (262) 628-0555
- NPI assigned
- Nov 22, 2006
- Last updated
- Apr 29, 2011
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 5492015 | WI | Primary |
Addresses
Primary practice location
N95W25901 Cty Hwy Q
Suite I
Colgate, WI 53017-9225
Mailing address
N95W25901 Cty Hwy Q
Suite I
Colgate, WI 53017-9225
Phone (262) 628-0555
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 33793900 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5492015 | WI | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Lorenz Dental LLC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1164153600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1304035200000",
"number": "1619042686",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "N95W25901 CTY HWY Q",
"address_2": "SUITE I",
"city": "COLGATE",
"state": "WI",
"postal_code": "530179225",
"telephone_number": "262-628-0555"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "N95W25901 CTY HWY Q",
"address_2": "SUITE I",
"city": "COLGATE",
"state": "WI",
"postal_code": "530179225",
"telephone_number": "262-628-0555"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JAKUSZ",
"first_name": "BRIAN",
"middle_name": "R",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-11-22",
"last_updated": "2011-04-29",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "WI",
"license": "5492015",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "33793900",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Colgate, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.