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General NPI Number Information
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NPI Number | 1043340417
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Entity Type | Organization
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Legal Business Name | WISCONSIN DENTAL GROUP, S.C.
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 04/15/2022
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Provider Practice Location Address
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Address Line | 1575 N RIVERCENTER DR STE 200
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City | MILWAUKEE
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State | WI
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Zip | 53212-3965
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Country | US
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Telephone | 414-276-5453
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Fax | 414-276-1715
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Provider Business Mailing Address
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Address Line | 1575 N RIVERCENTER DR STE 200
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City | MILWAUKEE
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State | WI
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Zip | 53212-3965
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Country | US
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Telephone | 414-276-5453
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Fax | 414-276-1715
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | CELIA HAYES
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Credential |
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Telephone | 217-540-2100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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