Provider Demographics
NPI:1104950336
Name:OAK RIDGE DENTAL CLINIC,SC
Entity type:Organization
Organization Name:OAK RIDGE DENTAL CLINIC,SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-261-5400
Mailing Address - Street 1:101 OAKRIDGE COURT
Mailing Address - Street 2:SUITE C
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4100
Mailing Address - Country:US
Mailing Address - Phone:920-261-5400
Mailing Address - Fax:920-261-1590
Practice Address - Street 1:101 OAKRIDGE COURT
Practice Address - Street 2:SUITE C
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4100
Practice Address - Country:US
Practice Address - Phone:920-261-5400
Practice Address - Fax:920-261-1590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33741400Medicaid
WI33354400Medicaid