=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457523649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED DENTAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2008
-----------------------------------------------------
Last Update Date | 03/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2727 W CLEVELAND AVE 2ND FL
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53215-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-383-5500
-----------------------------------------------------
Fax | 414-383-5400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2727 W CLEVELAND AVE 2ND FL
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-383-5500
-----------------------------------------------------
Fax | 414-383-5400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DDS
-----------------------------------------------------
Name | DR. LARRY TRAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 414-383-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 4911
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------