Provider Demographics
NPI:1083891261
Name:GREGORY A. SANTARELLI DDS SC
Entity Type:Organization
Organization Name:GREGORY A. SANTARELLI DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-654-6770
Mailing Address - Street 1:5017 GREEN BAY RD STE 138
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1782
Mailing Address - Country:US
Mailing Address - Phone:262-654-6770
Mailing Address - Fax:262-654-6727
Practice Address - Street 1:5017 GREEN BAY RD STE 138
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1782
Practice Address - Country:US
Practice Address - Phone:262-654-6770
Practice Address - Fax:262-654-6727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51880151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIV0325Medicare UPIN
WI000079992Medicare PIN