Healthcare Provider Details

I. General information

NPI: 1437552841
Provider Name (Legal Business Name): DENTISTRY OF WEST BEND, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 CHESTNUT ST
WEST BEND WI
53095-3130
US

IV. Provider business mailing address

1270 CHESTNUT ST
WEST BEND WI
53095-3130
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-0316
  • Fax:
Mailing address:
  • Phone: 262-334-0316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number6537-15
License Number StateWI

VIII. Authorized Official

Name: DR. JARED JOHN HARDING
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 608-886-0223