Provider Demographics
NPI:1023073178
Name:EAST GROVE DENTAL SC
Entity type:Organization
Organization Name:EAST GROVE DENTAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LYSLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-222-8344
Mailing Address - Street 1:826 ATLAS AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-3114
Mailing Address - Country:US
Mailing Address - Phone:608-222-8344
Mailing Address - Fax:608-222-8376
Practice Address - Street 1:826 ATLAS AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-3114
Practice Address - Country:US
Practice Address - Phone:608-222-8344
Practice Address - Fax:608-222-8376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1727G1223G0001X
WI28081223G0001X
WI51331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty