Healthcare Provider Details

I. General information

NPI: 1760538490
Provider Name (Legal Business Name): WISCONSIN ORAL SURGERY & DENTAL IMPLANTS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 W LINCOLN AVE SUITE 101
WEST ALLIS WI
53227-1255
US

IV. Provider business mailing address

10401 W LINCOLN AVE SUITE 101
WEST ALLIS WI
53227-1255
US

V. Phone/Fax

Practice location:
  • Phone: 414-327-4130
  • Fax: 414-327-4218
Mailing address:
  • Phone: 414-327-4130
  • Fax: 414-327-4218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5420-015
License Number StateWI

VIII. Authorized Official

Name: DR. ANTHONY L RAGONESE
Title or Position: PRESIDENT
Credential: DDS
Phone: 414-327-4130