Healthcare Provider Details

I. General information

NPI: 1053972661
Provider Name (Legal Business Name): OCONOMOWOC DENTAL ANESTHESIA CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 THACKERAY TRL STE 214
OCONOMOWOC WI
53066-4342
US

IV. Provider business mailing address

888 THACKERAY TRL STE 214
OCONOMOWOC WI
53066-4342
US

V. Phone/Fax

Practice location:
  • Phone: 262-567-9116
  • Fax:
Mailing address:
  • Phone: 262-567-9116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HENRY HOPKINSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 321-514-4992