Provider Demographics
NPI:1003942319
Name:SOUTHWEST DENTAL GROUP, S.C.
Entity Type:Organization
Organization Name:SOUTHWEST DENTAL GROUP, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEFURIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-632-3156
Mailing Address - Street 1:2601 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2865
Mailing Address - Country:US
Mailing Address - Phone:262-632-3156
Mailing Address - Fax:262-632-3063
Practice Address - Street 1:2601 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2865
Practice Address - Country:US
Practice Address - Phone:262-632-3156
Practice Address - Fax:262-632-3063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty