Provider Demographics
NPI:1215740576
Name:WISCONSIN DENTAL TEAM, A SERVICE CORPORATION
Entity type:Organization
Organization Name:WISCONSIN DENTAL TEAM, A SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEJANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-572-9671
Mailing Address - Street 1:9709 LAKESIDE BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77381-1213
Mailing Address - Country:US
Mailing Address - Phone:713-489-2198
Mailing Address - Fax:713-489-2978
Practice Address - Street 1:805 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4241
Practice Address - Country:US
Practice Address - Phone:414-567-0662
Practice Address - Fax:414-249-6075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty