Provider Demographics
NPI:1013409002
Name:WISCONSIN ORAL & MAXILLOFACIAL SURGERY LLC
Entity Type:Organization
Organization Name:WISCONSIN ORAL & MAXILLOFACIAL SURGERY LLC
Other - Org Name:WHITE OAK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:EJLAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ALALAWI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:914-325-5672
Mailing Address - Street 1:124 LEGEND WAY
Mailing Address - Street 2:
Mailing Address - City:WALES
Mailing Address - State:WI
Mailing Address - Zip Code:53183-9539
Mailing Address - Country:US
Mailing Address - Phone:914-325-5672
Mailing Address - Fax:
Practice Address - Street 1:2603 W RAWSON AVE STE 123
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8422
Practice Address - Country:US
Practice Address - Phone:914-325-5672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental