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General NPI Number Information
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NPI Number | 1134111974
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Entity Type | Organization
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Legal Business Name | MAPLE GROVE DENTAL SC
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Dates
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Enumeration Date | 08/18/2005
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Last Update Date | 01/26/2011
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Provider Practice Location Address
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Address Line | 6627 MCKEE RD
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City | MADISON
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State | WI
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Zip | 53719-5023
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Country | US
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Telephone | 608-848-5680
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Fax | 608-848-5681
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Provider Business Mailing Address
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Address Line | 6627 MCKEE RD
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City | MADISON
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State | WI
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Zip | 53719-5023
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Country | US
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Telephone | 608-848-5680
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Fax | 608-848-5681
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. JAMES CARL TAUSCHEK
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Credential | DDS
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Telephone | 608-848-5680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 30018639
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | WI3998
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License Number State | WI
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