MEDICARE: THIRD WARD DENTAL, SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	3071	WI

General Provider Information

NPI Number	:	1285788349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THIRD WARD DENTAL, SC

Provider Business Mailing Address
First Line	:	219 N MILWAUKEE ST FL 5
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-5818
Country	:	US
Telephone Number	:	414-273-9800
Fax Number	:	414-273-9807

Provider Business Practice Location Address
First Line	:	219 N MILWAUKEE ST FL 5
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-5818
Country	:	US
Telephone Number	:	414-273-9800
Fax Number	:	414-273-9807

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN R. MOSER
Credential	:	DDS
Telephone Number	:	414-273-9800

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	08/22/2020

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