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General NPI Number Information
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NPI Number | 1982385944
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Entity Type | Organization
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Legal Business Name | WATERFORD CHILDRENS DENTISTRY SC
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Dates
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Enumeration Date | 07/31/2023
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Last Update Date | 07/31/2023
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Provider Practice Location Address
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Address Line | 790 CORNERSTONE XING
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City | WATERFORD
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State | WI
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Zip | 53185-4582
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Country | US
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Telephone | 414-350-0945
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Fax |
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Provider Business Mailing Address
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Address Line | 790 CORNERSTONE XING
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City | WATERFORD
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State | WI
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Zip | 53185-4582
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Country | US
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Telephone | 414-350-0945
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHRISTY FRADY
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Credential | DMD
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Telephone | 414-350-0945
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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