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NPI Code Detail

MEDICARE: KEYSTONE WEST ALLIS LLC WEST ALLIS DENTAL CARE

MEDICARE: KEYSTONE WEST ALLIS LLC WEST ALLIS DENTAL CARE
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
1261QD0000XDental Clinic/Center

General Provider Information

NPI Number : 1588297584
Entity Type Code : Organization
Provider Name (Legal Business Name) : KEYSTONE WEST ALLIS LLC WEST ALLIS DENTAL CARE
Provider Business Mailing Address
First Line : PO BOX 180163
Second Line :
City : DELAFIELD
State : WI
Zip : 53018-0163
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 7130 W GREENFIELD AVE
Second Line :
City : WEST ALLIS
State : WI
Zip : 53214-4708
Country : US
Telephone Number : 414-258-2500
Fax Number :
Authorized Official
Title or Position : OPERATIONS MANAGER
Name : TAMMY KEVIN
Credential :
Telephone Number : 262-873-0510
Provider Enumeration Date : 02/18/2020
Last Update Date : 02/18/2020

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