Provider Demographics
NPI:1316315351
Name:INTEGRATIVE DENTAL SOLUTIONS LLC
Entity type:Organization
Organization Name:INTEGRATIVE DENTAL SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUPRIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-691-4555
Mailing Address - Street 1:N35W23770 CAPITOL DR STE E
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-2639
Mailing Address - Country:US
Mailing Address - Phone:262-691-4555
Mailing Address - Fax:262-691-4579
Practice Address - Street 1:N35W23770 CAPITOL DR STE E
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-2639
Practice Address - Country:US
Practice Address - Phone:262-691-4555
Practice Address - Fax:262-691-4579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No122300000XDental ProvidersDentistGroup - Single Specialty