=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801676721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANDVIEW DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2023
-----------------------------------------------------
Last Update Date | 09/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 811 N GRANDVIEW BLVD
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53188-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-412-8948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5449 S SUNNY SLOPE RD
-----------------------------------------------------
City | NEW BERLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53151-8075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-412-8948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | JONATHAN EDWARD AIUPPA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 414-412-8948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------