Provider Demographics
NPI:1215948377
Name:CHILDREN'S DENTAL CARE OF KENOSHA
Entity type:Organization
Organization Name:CHILDREN'S DENTAL CARE OF KENOSHA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:262-658-3488
Mailing Address - Street 1:2901 35TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-5119
Mailing Address - Country:US
Mailing Address - Phone:262-658-3488
Mailing Address - Fax:262-658-3433
Practice Address - Street 1:2901 35TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5119
Practice Address - Country:US
Practice Address - Phone:262-658-3488
Practice Address - Fax:262-658-3433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========OtherTAX ID
WI38383500Medicare ID - Type Unspecified