Provider Demographics
NPI:1053312389
Name:FAMILY DENTAL OF SOUTH EAST WISCONSIN, S.C.
Entity Type:Organization
Organization Name:FAMILY DENTAL OF SOUTH EAST WISCONSIN, S.C.
Other - Org Name:PETER M WILSENS DDS SC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-321-2720
Mailing Address - Street 1:10202 W HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2042
Mailing Address - Country:US
Mailing Address - Phone:414-321-2720
Mailing Address - Fax:414-321-7718
Practice Address - Street 1:10202 W HAYES AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2042
Practice Address - Country:US
Practice Address - Phone:414-321-2720
Practice Address - Fax:414-321-7718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2304122300000X
WI3499122300000X
WI6783122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty