Provider Demographics
NPI:1962150417
Name:WISCONSIN DENTAL GROUP, S.C.
Entity type:Organization
Organization Name:WISCONSIN DENTAL GROUP, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:7955 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-1901
Mailing Address - Country:US
Mailing Address - Phone:414-216-9211
Mailing Address - Fax:
Practice Address - Street 1:7955 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1901
Practice Address - Country:US
Practice Address - Phone:414-216-9211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN DENTAL GROUP, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty