MEDICARE: DANIEL OH D.D.S.

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	9094724-9921	UT
2	122300000X	Dentist	6001145-15	WI
3	1223G0001X	General Practice Dentistry	019.031524	IL
4	1223E0200X	Endodontics	021.003070	IL

General Provider Information

NPI Number	:	1689073041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL OH D.D.S.

Provider Business Mailing Address
First Line	:	7500 GREEN BAY RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-4059
Country	:	US
Telephone Number	:	714-452-7178
Fax Number	:

Provider Business Practice Location Address
First Line	:	7500 GREEN BAY RD STE 200
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-4045
Country	:	US
Telephone Number	:	714-452-7178
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2014
Last Update Date	:	01/22/2024

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