Healthcare Provider Details

I. General information

NPI: 1417169160
Provider Name (Legal Business Name): CHILDREN'S DENTAL CENTER OF MADISON, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 OLD SAUK ROAD #200
MADISON WI
53717
US

IV. Provider business mailing address

7001 OLD SAUK ROAD #200
MADISON WI
53717
US

V. Phone/Fax

Practice location:
  • Phone: 608-833-6545
  • Fax: 608-833-8516
Mailing address:
  • Phone: 608-833-6545
  • Fax: 608-833-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberWI3347
License Number StateWI

VIII. Authorized Official

Name: DR. TIMOTHY R KINZEL
Title or Position: VICE-PRESIDENT
Credential: DDS
Phone: 608-833-6545