Healthcare Provider Details

I. General information

NPI: 1164047130
Provider Name (Legal Business Name): MEQUON DEER DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 W BROWN DEER RD
MILWAUKEE WI
53223-2078
US

IV. Provider business mailing address

8025 EXCELSIOR DR
MADISON WI
53717-1900
US

V. Phone/Fax

Practice location:
  • Phone: 414-354-1160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OLGA GRENOVA
Title or Position: DIR OF ACCOUNTING
Credential:
Phone: 608-833-2213