Provider Demographics
NPI:1073021465
Name:WHITNALL DENTAL
Entity type:Organization
Organization Name:WHITNALL DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-646-2771
Mailing Address - Street 1:920 INDIAN SPRING DR
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2242
Mailing Address - Country:US
Mailing Address - Phone:262-646-2771
Mailing Address - Fax:
Practice Address - Street 1:6522 S LOVERS LANE RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-1209
Practice Address - Country:US
Practice Address - Phone:414-425-1101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty