Healthcare Provider Details

I. General information

NPI: 1760192736
Provider Name (Legal Business Name): WISCONSIN MOBILE DENTAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2022
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6428 N CALIFORNIA AVE
CHICAGO IL
60645-5209
US

IV. Provider business mailing address

833 CHATHAM RD
GLENVIEW IL
60025-4405
US

V. Phone/Fax

Practice location:
  • Phone: 847-804-9429
  • Fax:
Mailing address:
  • Phone: 847-804-9429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER CONTOS
Title or Position: OWNER
Credential: DDS
Phone: 847-804-9429