Provider Demographics
NPI:1063160521
Name:WISCONSIN DENTAL GROUP, S.C.
Entity type:Organization
Organization Name:WISCONSIN DENTAL GROUP, S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:8001 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4507
Mailing Address - Country:US
Mailing Address - Phone:608-231-2006
Mailing Address - Fax:
Practice Address - Street 1:8001 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4507
Practice Address - Country:US
Practice Address - Phone:608-231-2006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN DENTAL GROUP, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-14
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty