Healthcare Provider Details

I. General information

NPI: 1427463199
Provider Name (Legal Business Name): ADVANCED DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2014
Last Update Date: 06/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6425 W GREENFIELD AVE
WEST ALLIS WI
53214-4939
US

IV. Provider business mailing address

6425 W GREENFIELD AVE
WEST ALLIS WI
53214-4939
US

V. Phone/Fax

Practice location:
  • Phone: 414-914-7000
  • Fax: 414-914-8000
Mailing address:
  • Phone: 414-914-7000
  • Fax: 414-914-8000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6839-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6839-15
License Number StateWI

VIII. Authorized Official

Name: DR. TAWFIQ S NADI
Title or Position: PRESIDENT
Credential: DDS
Phone: 414-914-7000