Provider Demographics
NPI:1437236536
Name:RIDGEVIEW DENTAL GROUP SC
Entity type:Organization
Organization Name:RIDGEVIEW DENTAL GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PRUHS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-251-5355
Mailing Address - Street 1:W178 N9201 WATER TOWER PLACE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051
Mailing Address - Country:US
Mailing Address - Phone:262-251-8704
Mailing Address - Fax:262-251-8341
Practice Address - Street 1:W178 N9201 WATER TOWER PLACE
Practice Address - Street 2:SUITE 100
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051
Practice Address - Country:US
Practice Address - Phone:262-251-8704
Practice Address - Fax:262-251-8341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 1223P0221X, 1223X0400X
WI00040631223G0001X
WI53340151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty