Healthcare Provider Details

I. General information

NPI: 1548008022
Provider Name (Legal Business Name): DENTAL IMPLANTS & PERIODONTAL SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 MINERAL POINT RD
MADISON WI
53705-4239
US

IV. Provider business mailing address

6601 MINERAL POINT RD
MADISON WI
53705-4239
US

V. Phone/Fax

Practice location:
  • Phone: 608-841-1600
  • Fax: 608-841-1602
Mailing address:
  • Phone: 608-841-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: MRS. STELLA MARIE HULSE-CRISTOFORO
Title or Position: CFO
Credential:
Phone: 516-835-6777