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General NPI Number Information
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NPI Number | 1568275071
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Entity Type | Organization
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Legal Business Name | AHP 004 LLC
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Dates
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Enumeration Date | 01/29/2025
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Last Update Date | 01/29/2025
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Provider Practice Location Address
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Address Line | W236S7050 BIG BEND DR STE 7
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City | BIG BEND
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State | WI
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Zip | 53103-9497
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Country | US
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Telephone | 262-662-1111
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Fax |
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Provider Business Mailing Address
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Address Line | 15285 WATERTOWN PLANK RD STE 200
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City | ELM GROVE
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State | WI
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Zip | 53122-2339
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Country | US
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Telephone | 262-649-4900
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | KATE MANTAY
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Credential |
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Telephone | 262-649-4900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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