MEDICARE: WISCONSIN SMILES

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1699128082	OTHER		CMS-NPI

General Provider Information

NPI Number	:	1467059865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISCONSIN SMILES

Provider Business Mailing Address
First Line	:	6719 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2041
Country	:	US
Telephone Number	:	414-464-6300
Fax Number	:	414-464-2874

Provider Business Practice Location Address
First Line	:	6719 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2041
Country	:	US
Telephone Number	:	414-464-6300
Fax Number	:	414-464-2874

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. HIDAYATHULLA KHAN
Credential	:	DMD
Telephone Number	:	224-766-9876

Provider Enumeration Date	:	10/08/2020
Last Update Date	:	10/08/2020

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Directions to “WISCONSIN SMILES ” Practice Location

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