Healthcare Provider Details

I. General information

NPI: 1689942195
Provider Name (Legal Business Name): SMILE WISCONSIN LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E WISCONSIN AVE SUITE 1800
MILWAUKEE WI
53202-4232
US

IV. Provider business mailing address

33533 W 12 MILE RD SUITE 150
FARMINGTON HILLS MI
48331-3354
US

V. Phone/Fax

Practice location:
  • Phone: 888-833-8441
  • Fax: 888-330-4331
Mailing address:
  • Phone: 888-833-8441
  • Fax: 888-330-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6817-15
License Number StateWI

VIII. Authorized Official

Name: SOLOMON K. PESIS
Title or Position: DENTAL DIRECTOR
Credential: DDS
Phone: 888-833-8441