Provider Demographics
NPI:1104207232
Name:DENTAL CARE PROVIDERS OF AMERICA
Entity Type:Organization
Organization Name:DENTAL CARE PROVIDERS OF AMERICA
Other - Org Name:DENTAL CARE OF KENOSHA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:KISKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:224-645-4929
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53141-0788
Mailing Address - Country:US
Mailing Address - Phone:262-842-2877
Mailing Address - Fax:877-725-4332
Practice Address - Street 1:3715 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1629
Practice Address - Country:US
Practice Address - Phone:262-237-6238
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001058-15261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental