Provider Demographics
NPI:1144618125
Name:OAKBROOK DENTAL, S.C.
Entity Type:Organization
Organization Name:OAKBROOK DENTAL, S.C.
Other - Org Name:OAKBROOK DENTAL S.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:D.D.S.
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIMONSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-389-0300
Mailing Address - Street 1:1201 OAK ST STE P
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-3800
Mailing Address - Country:US
Mailing Address - Phone:262-335-0822
Mailing Address - Fax:262-335-0814
Practice Address - Street 1:1201 OAK ST STE P
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3800
Practice Address - Country:US
Practice Address - Phone:262-335-0822
Practice Address - Fax:262-335-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
WI3652122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3652OtherSTATE OF WISCONSIN
BS0676277OtherDEA
WI6922OtherSTATE OF WISCONSIN