=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407257108
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE KIDS DENTIST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2014
-----------------------------------------------------
Last Update Date | 09/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10618 N PORT WASHINGTON RD
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-241-0400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10618 N PORT WASHINGTON RD
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-241-0400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SHANE FISHER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 262-241-0400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 5127-015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------