=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689487191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AHP 003 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2025
-----------------------------------------------------
Last Update Date | 01/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7020 W NATIONAL AVE STE 100
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53214-4843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-475-0588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15285 WATERTOWN PLANK RD STE 200
-----------------------------------------------------
City | ELM GROVE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53122-2339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-649-4900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | KATE MANTAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-649-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------