Provider Demographics
NPI:1053814772
Name:WAUKESHA COUNTY COMMUNITY DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:WAUKESHA COUNTY COMMUNITY DENTAL CLINIC, INC.
Other - Org Name:WAUKESHA COUNTY COMMUNITY DENTAL CLINIC - MENOMONEE FALLS
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-953-4699
Mailing Address - Street 1:210 NW BARSTOW ST STE 305
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3771
Mailing Address - Country:US
Mailing Address - Phone:262-953-4699
Mailing Address - Fax:262-522-2828
Practice Address - Street 1:N81W15062 APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051
Practice Address - Country:US
Practice Address - Phone:262-953-4699
Practice Address - Fax:262-522-2828
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAUKESHA COUNTY COMMUNITY DENTAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-09
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38398500Medicaid