Healthcare Provider Details

I. General information

NPI: 1235111535
Provider Name (Legal Business Name): DENNIS G VINCENT M D S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14555 W NATIONAL AVE STE 175
NEW BERLIN WI
53157-4484
US

IV. Provider business mailing address

14555 W NATIONAL AVE STE 175
NEW BERLIN WI
53157-4484
US

V. Phone/Fax

Practice location:
  • Phone: 262-827-3144
  • Fax: 262-827-3150
Mailing address:
  • Phone: 262-827-3144
  • Fax: 262-827-3150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number29313 020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number29313 020
License Number StateWI

VIII. Authorized Official

Name: DENNIS GALEN VINCENT
Title or Position: PRESIDENT
Credential: MD
Phone: 262-827-3144