Provider Demographics
NPI:1487738068
Name:THE ORTHODONTIC CARE CENTER
Entity type:Organization
Organization Name:THE ORTHODONTIC CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:KUMAR
Authorized Official - Middle Name:V
Authorized Official - Last Name:IYER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-771-5100
Mailing Address - Street 1:1421 S 108 STREET
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4012
Mailing Address - Country:US
Mailing Address - Phone:414-771-5100
Mailing Address - Fax:414-771-2513
Practice Address - Street 1:1421 S 108 STREET
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4012
Practice Address - Country:US
Practice Address - Phone:414-771-5100
Practice Address - Fax:414-771-2513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33448200Medicaid