Healthcare Provider Details

I. General information

NPI: 1043340417
Provider Name (Legal Business Name): WISCONSIN DENTAL GROUP, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 N RIVERCENTER DR STE 200
MILWAUKEE WI
53212-3965
US

IV. Provider business mailing address

1575 N RIVERCENTER DR STE 200
MILWAUKEE WI
53212-3965
US

V. Phone/Fax

Practice location:
  • Phone: 414-276-5453
  • Fax: 414-276-1715
Mailing address:
  • Phone: 414-276-5453
  • Fax: 414-276-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CELIA HAYES
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100