NPIMap

Organization Active NPI

Cedar Lake Dental Professionals LTD

  • General Practice Dentistry
  • West Bend, WI
National Provider Identifier
1790840734
Registry record updated Sep 11, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
4368 Issued in WI
Legal business name
CEDAR LAKE DENTAL PROFESSIONALS LTD
Practice address
145 N 18TH Avenue
West Bend, WI 53095
Phone
(262) 334-3084
Fax
(262) 334-3552
NPI assigned
Dec 27, 2006
Last updated
Sep 11, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 11, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Lysette L Brueggeman, DDSNPI 1639234677
Title
Owner
Phone
(262) 334-3084

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X 4368 WI Primary
Prosthodontics 1223P0700X 4408 WI

Addresses

Primary practice location

145 N 18TH Avenue
West Bend, WI 53095

Mailing address

145 N 18TH Avenue
West Bend, WI 53095
Phone (262) 334-3084

Other identifiers 3

IdentifierTypeStateIssuer
33713000MedicaidWI
33761800OtherWIMEDICAID
650286OtherUNITED CONCORDIA

National Provider Directory

National Provider Directory

Locations

145 N 18th Ave
West Bend, WI 53095
Phone (262) 334-3084

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1167177600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1757548800000",
    "number": "1790840734",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "145 N 18TH AVENUE",
            "city": "WEST BEND",
            "state": "WI",
            "postal_code": "53095",
            "telephone_number": "262-334-3084",
            "fax_number": "262-334-3552"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "145 N 18TH AVENUE",
            "city": "WEST BEND",
            "state": "WI",
            "postal_code": "53095",
            "telephone_number": "262-334-3084",
            "fax_number": "262-334-3552"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CEDAR LAKE DENTAL PROFESSIONALS LTD",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-27",
        "last_updated": "2025-09-11",
        "status": "A",
        "authorized_official_last_name": "BRUEGGEMAN",
        "authorized_official_first_name": "LYSETTE",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "262-334-3084",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "WI",
            "license": "4368",
            "primary": true
        },
        {
            "code": "1223P0700X",
            "taxonomy_group": "",
            "desc": "Dentist, Prosthodontics",
            "state": "WI",
            "license": "4408",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33713000",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAID",
            "identifier": "33761800",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED CONCORDIA",
            "identifier": "650286",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in West Bend, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.