Provider Demographics
NPI:1588297584
Name:KEYSTONE WEST ALLIS LLC WEST ALLIS DENTAL CARE
Entity type:Organization
Organization Name:KEYSTONE WEST ALLIS LLC WEST ALLIS DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-873-0510
Mailing Address - Street 1:PO BOX 180163
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-0163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7130 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4708
Practice Address - Country:US
Practice Address - Phone:414-258-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental