Provider Demographics
NPI:1427463199
Name:ADVANCED DENTAL
Entity type:Organization
Organization Name:ADVANCED DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAWFIQ
Authorized Official - Middle Name:S
Authorized Official - Last Name:NADI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-914-7000
Mailing Address - Street 1:6425 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4939
Mailing Address - Country:US
Mailing Address - Phone:414-914-7000
Mailing Address - Fax:414-914-8000
Practice Address - Street 1:6425 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4939
Practice Address - Country:US
Practice Address - Phone:414-914-7000
Practice Address - Fax:414-914-8000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-21
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6839-151223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty