MEDICARE: WISNOVA LLC

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	1223E0200X	Endodontics

General Provider Information

NPI Number	:	1881573806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISNOVA LLC

Provider Business Mailing Address
First Line	:	5021 WASHINGTON RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-4292
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5021 WASHINGTON RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-4292
Country	:	US
Telephone Number	:	262-632-5455
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ENDODONTIST
Name	:	CODY NELSON
Credential	:	DMD
Telephone Number	:	412-266-8924

Provider Enumeration Date	:	09/02/2025
Last Update Date	:	09/02/2025

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Directions to “WISNOVA LLC ” Practice Location

Language	Start Address	Practice Location

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