Healthcare Provider Details

I. General information

NPI: 1215948377
Provider Name (Legal Business Name): CHILDREN'S DENTAL CARE OF KENOSHA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 35TH ST
KENOSHA WI
53140-5119
US

IV. Provider business mailing address

2901 35TH ST
KENOSHA WI
53140-5119
US

V. Phone/Fax

Practice location:
  • Phone: 262-658-3488
  • Fax: 262-658-3433
Mailing address:
  • Phone: 262-658-3488
  • Fax: 262-658-3433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DENNIS M CONNOLLY
Title or Position: PRESIDENT
Credential: DDS MS
Phone: 262-658-3488