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NPI Code Detail

MEDICARE: ANTISDEL DENTAL CLINIC, S.C.

MEDICARE: ANTISDEL DENTAL CLINIC, 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
11223G0001XGeneral Practice Dentistry2485-015 / 2486-015WI

General Provider Information

NPI Number : 1649294257
Entity Type Code : Organization
Provider Name (Legal Business Name) : ANTISDEL DENTAL CLINIC, S.C.
Provider Business Mailing Address
First Line : 661 E GREEN BAY AVE
Second Line :
City : SAUKVILLE
State : WI
Zip : 53080-2013
Country : US
Telephone Number : 262-284-7111
Fax Number : 262-284-1172
Provider Business Practice Location Address
First Line : 661 E GREEN BAY AVE
Second Line :
City : SAUKVILLE
State : WI
Zip : 53080-2013
Country : US
Telephone Number : 262-284-7111
Fax Number : 262-284-1172
Authorized Official
Title or Position : PRESIDENT / DENTIST
Name : DR. ROBERT JAMES ANTISDEL
Credential : D.D.S.
Telephone Number : 12622847111
Provider Enumeration Date : 07/27/2006
Last Update Date : 08/22/2020

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