Healthcare Provider Details

I. General information

NPI: 1427564897
Provider Name (Legal Business Name): OCDC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 E DREXEL AVE
OAK CREEK WI
53154-2123
US

IV. Provider business mailing address

132 E DREXEL AVE
OAK CREEK WI
53154-2123
US

V. Phone/Fax

Practice location:
  • Phone: 414-762-9010
  • Fax:
Mailing address:
  • Phone: 414-762-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number6560
License Number StateWI

VIII. Authorized Official

Name: DR. EHSAN SALEKI
Title or Position: DENTIST
Credential: DDS
Phone: 414-762-9010