Healthcare Provider Details

I. General information

NPI: 1043091630
Provider Name (Legal Business Name): DENTISTRYONE OF WISCONSIN SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6709 RAYMOND RD
MADISON WI
53719-3943
US

IV. Provider business mailing address

20 HIGHLAND AVE
METUCHEN NJ
08840-1949
US

V. Phone/Fax

Practice location:
  • Phone: 877-712-7875
  • Fax:
Mailing address:
  • Phone: 877-712-7875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: HILLARY BERRY
Title or Position: CEO
Credential: DDS
Phone: 877-712-7875