MEDICARE: WISCONSIN DENTAL GROUP, S.C.

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	122300000X	Dentist
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1437289006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISCONSIN DENTAL GROUP, S.C.

Provider Business Mailing Address
First Line	:	3715 WASHINGTON RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-1629
Country	:	US
Telephone Number	:	414-351-6010
Fax Number	:	414-351-6148

Provider Business Practice Location Address
First Line	:	3620 57TH AVE STE 600
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-4925
Country	:	US
Telephone Number	:	414-351-6010
Fax Number	:	414-351-6148

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	CELIA HAYES
Credential	:
Telephone Number	:	217-540-2100

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	05/03/2022

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