Healthcare Provider Details

I. General information

NPI: 1942949573
Provider Name (Legal Business Name): ORTHODONTIC EXPERTS OF WISCONSIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

5778 S 108TH ST
HALES CORNERS WI
53130-1947
US

IV. Provider business mailing address

1250 W NORTHWEST HWY
MOUNT PROSPECT IL
60056-2274
US

V. Phone/Fax

Practice location:
  • Phone: 414-600-0120
  • Fax:
Mailing address:
  • Phone: 847-749-4340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MONIKA BZDAL
Title or Position: VP OF SUPPORT SERVICES
Credential:
Phone: 815-340-1046