Provider Demographics
NPI:1043091630
Name:DENTISTRYONE OF WISONSIN SC
Entity Type:Organization
Organization Name:DENTISTRYONE OF WISONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HILLARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:877-712-7875
Mailing Address - Street 1:460 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840-1834
Mailing Address - Country:US
Mailing Address - Phone:877-712-7875
Mailing Address - Fax:
Practice Address - Street 1:6709 RAYMOND RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-3943
Practice Address - Country:US
Practice Address - Phone:877-712-7875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty