Healthcare Provider Details

I. General information

NPI: 1003849100
Provider Name (Legal Business Name): DHA ORTHODONTICS WEST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 OLD SAUK RD SUITE 101
MADISON WI
53717-2307
US

IV. Provider business mailing address

7007 OLD SAUK RD SUITE 101
MADISON WI
53717-2307
US

V. Phone/Fax

Practice location:
  • Phone: 608-833-6112
  • Fax: 608-661-6437
Mailing address:
  • Phone: 608-833-6112
  • Fax: 608-661-6437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DAVID T ALLEN
Title or Position: PRIVACY OFFICIAL
Credential: DDS
Phone: 608-833-6112