Healthcare Provider Details

I. General information

NPI: 1134111974
Provider Name (Legal Business Name): MAPLE GROVE DENTAL SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6627 MCKEE RD
MADISON WI
53719-5023
US

IV. Provider business mailing address

6627 MCKEE RD
MADISON WI
53719-5023
US

V. Phone/Fax

Practice location:
  • Phone: 608-848-5680
  • Fax: 608-848-5681
Mailing address:
  • Phone: 608-848-5680
  • Fax: 608-848-5681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30018639
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberWI3998
License Number StateWI

VIII. Authorized Official

Name: DR. JAMES CARL TAUSCHEK
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 608-848-5680