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General NPI Number Information
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NPI Number | 1215388616
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Entity Type | Organization
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Legal Business Name | ADVANCED ORTHODONTICS OF WISCONSIN
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Dates
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Enumeration Date | 06/27/2016
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Last Update Date | 06/27/2016
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Provider Practice Location Address
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Address Line | 5605 ODANA RD
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City | MADISON
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State | WI
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Zip | 53719-1207
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Country | US
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Telephone | 608-271-9293
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Fax | 608-204-9216
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Provider Business Mailing Address
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Address Line | 5605 ODANA RD
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City | MADISON
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State | WI
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Zip | 53719-1207
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Country | US
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Telephone | 608-271-9293
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Fax |
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Authorized Official
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Title or Position | DR./OWNER
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Name | DR. MARTIN D GOCHNOUR
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Credential | DDS, MS
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Telephone | 608-271-9293
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 5066
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License Number State | TX
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