MEDICARE: WEST ENDODONTIC GROUP

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	1223E0200X	Endodontics	6129-15	WI

General Provider Information

NPI Number	:	1417284480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST ENDODONTIC GROUP

Provider Business Mailing Address
First Line	:	1245 CHEYENNE AVE
Second Line	:	SUITE 104
City	:	GRAFTON
State	:	WI
Zip	:	53024-9323
Country	:	US
Telephone Number	:	262-377-2889
Fax Number	:	262-377-2680

Provider Business Practice Location Address
First Line	:	1245 CHEYENNE AVE
Second Line	:	SUITE 104
City	:	GRAFTON
State	:	WI
Zip	:	53024-9323
Country	:	US
Telephone Number	:	262-377-2889
Fax Number	:	262-377-2680

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KELLY NICOLE WEST
Credential	:	DDS
Telephone Number	:	262-377-2668

Provider Enumeration Date	:	11/11/2009
Last Update Date	:	11/11/2009

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