Provider Demographics
NPI:1366572927
Name:WISCONSIN DENTAL GROUP, S.C.
Entity type:Organization
Organization Name:WISCONSIN DENTAL GROUP, S.C.
Other - Org Name:<UNAVAIL>
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 1:6218 WASHINGTON AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3916
Mailing Address - Country:US
Mailing Address - Phone:262-255-2727
Mailing Address - Fax:262-255-3903
Practice Address - Street 1:6218 WASHINGTON AVE STE C
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-3916
Practice Address - Country:US
Practice Address - Phone:262-886-1300
Practice Address - Fax:262-886-1837
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN DENTAL GROUP, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-06
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty