Healthcare Provider Details

I. General information

NPI: 1114863602
Provider Name (Legal Business Name): OSR DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2572 S 76TH ST
WEST ALLIS WI
53219-2476
US

IV. Provider business mailing address

2572 S 76TH ST
WEST ALLIS WI
53219-2476
US

V. Phone/Fax

Practice location:
  • Phone: 414-616-1986
  • Fax:
Mailing address:
  • Phone: 414-616-1986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ARCHANA LEE
Title or Position: OWNER
Credential:
Phone: 414-630-2100