MEDICARE: SOUTH SIDE GUADALUPE DENTAL CLINIC INC

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	1223G0001X	General Practice Dentistry		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598922122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SIDE GUADALUPE DENTAL CLINIC INC

Provider Business Mailing Address
First Line	:	1112 S 3RD ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-2413
Country	:	US
Telephone Number	:	414-643-8787
Fax Number	:	414-643-9725

Provider Business Practice Location Address
First Line	:	1112 S 3RD ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-2413
Country	:	US
Telephone Number	:	414-643-8787
Fax Number	:	414-643-9725

Authorized Official
Title or Position	:	CLINIC MANAGER
Name	:	MRS. MARIA LETICIA MONJE
Credential	:
Telephone Number	:	414-643-8787

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	05/21/2008

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