=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528716420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED DENTAL SPECIALISTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2022
-----------------------------------------------------
Last Update Date | 03/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | N14W23833 STONE RIDGE DR STE 100
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53188-1189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-278-3115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N14W23833 STONE RIDGE DR STE 100
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53188-1189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-278-3115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | CELIA HAYES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------