Healthcare Provider Details

I. General information

NPI: 1790399665
Provider Name (Legal Business Name): BAYSHORE DENTAL SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E SILVER SPRING DR
MILWAUKEE WI
53217-5224
US

IV. Provider business mailing address

400 E SILVER SPRING DR
MILWAUKEE WI
53217-5224
US

V. Phone/Fax

Practice location:
  • Phone: 414-332-6010
  • Fax: 414-322-1850
Mailing address:
  • Phone: 414-332-6010
  • Fax: 414-322-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: GAURI PATEL
Title or Position: OWNER
Credential: DDS
Phone: 414-332-6010