=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487738068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ORTHODONTIC CARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1421 S 108 STREET
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53214-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-771-5100
-----------------------------------------------------
Fax | 414-771-2513
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1421 S 108 STREET
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53214-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-771-5100
-----------------------------------------------------
Fax | 414-771-2513
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT ORTHODONTIST
-----------------------------------------------------
Name | KUMAR V IYER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 414-771-5100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 3019
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------