MEDICARE: NORTHRIDGE DENTAL CENTER S.C.

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	5001515-015	WI

General Provider Information

NPI Number	:	1730184557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHRIDGE DENTAL CENTER S.C.

Provider Business Mailing Address
First Line	:	2327 W APPLE TREE RD
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53209-3311
Country	:	US
Telephone Number	:	414-352-3839
Fax Number	:

Provider Business Practice Location Address
First Line	:	7906 N 76TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-3916
Country	:	US
Telephone Number	:	414-354-9020
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN A FITCH
Credential	:	D.D.S.
Telephone Number	:	414-354-9020

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	08/22/2020

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