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General NPI Number Information
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NPI Number | 1902975709
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Entity Type | Organization
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Legal Business Name | THE DOWNTOWN DENTAL GROUP
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 161 W WISCONSIN AVE SUITE 5036
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City | MILWAUKEE
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State | WI
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Zip | 53203-2602
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Country | US
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Telephone | 414-278-6070
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Fax | 414-278-6087
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Provider Business Mailing Address
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Address Line | 161 W WISCONSIN AVE SUITE 5036
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City | MILWAUKEE
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State | WI
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Zip | 53203-2602
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Country | US
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Telephone | 414-278-6070
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Fax | 414-278-6087
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICHAEL L COSTELLO
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Credential | DDS
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Telephone | 414-278-6070
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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 | 2736
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License Number State | WI
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