=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114863602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OSR DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2026
-----------------------------------------------------
Last Update Date | 04/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2572 S 76TH ST
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53219-2476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-616-1986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2572 S 76TH ST
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53219-2476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-616-1986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ARCHANA LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-630-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------