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General NPI Number Information
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NPI Number | 1316315351
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE DENTAL SOLUTIONS LLC
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Dates
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Enumeration Date | 09/08/2015
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Last Update Date | 09/08/2015
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Provider Practice Location Address
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Address Line | N35W23770 CAPITOL DR STE E
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City | PEWAUKEE
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State | WI
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Zip | 53072-2639
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Country | US
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Telephone | 262-691-4555
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Fax | 262-691-4579
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Provider Business Mailing Address
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Address Line | N35W23770 CAPITOL DR STE E
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City | PEWAUKEE
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State | WI
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Zip | 53072-2639
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Country | US
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Telephone | 262-691-4555
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Fax | 262-691-4579
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Authorized Official
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Title or Position | OWNER
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Name | SUPRIYA SHETTY
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Credential | DDS
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Telephone | 262-691-4555
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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