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General NPI Number Information
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NPI Number | 1588297584
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Entity Type | Organization
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Legal Business Name | KEYSTONE WEST ALLIS LLC WEST ALLIS DENTAL CARE
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Dates
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Enumeration Date | 02/18/2020
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Last Update Date | 02/18/2020
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Provider Practice Location Address
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Address Line | 7130 W GREENFIELD AVE
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City | WEST ALLIS
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State | WI
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Zip | 53214-4708
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Country | US
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Telephone | 414-258-2500
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 180163
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City | DELAFIELD
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State | WI
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Zip | 53018-0163
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | TAMMY KEVIN
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Credential |
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Telephone | 262-873-0510
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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