Healthcare Provider Details

I. General information

NPI: 1366572927
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: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6218 WASHINGTON AVE STE C
RACINE WI
53406-3916
US

IV. Provider business mailing address

6218 WASHINGTON AVE STE C
MT PLEASANT WI
53406-3916
US

V. Phone/Fax

Practice location:
  • Phone: 262-886-1300
  • Fax: 262-886-1837
Mailing address:
  • Phone: 262-255-2727
  • Fax: 262-255-3903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

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