MEDICARE: SCION DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305R00000X	Preferred Provider Organization

General Provider Information

NPI Number	:	1134543101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCION DENTAL

Provider Business Mailing Address
First Line	:	10201 N PORT WASHINGTON RD
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-5752
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10201 N PORT WASHINGTON RD
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-5752
Country	:	US
Telephone Number	:	262-834-6130
Fax Number	:	866-413-6397

Authorized Official
Title or Position	:	CFO/SECRETARY/TREASURER
Name	:	LISA A SWEENEY
Credential	:
Telephone Number	:	262-834-6130

Provider Enumeration Date	:	02/12/2014
Last Update Date	:	02/12/2014

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Directions to “SCION DENTAL ” Practice Location

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