Provider Demographics
NPI:1144764978
Name:SUMMIT SQUARE DENTAL LLC
Entity Type:Organization
Organization Name:SUMMIT SQUARE DENTAL LLC
Other - Org Name:SUMMIT SQUARE DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATHISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-709-8303
Mailing Address - Street 1:3228 TURNBERRY OAK DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3969
Mailing Address - Country:US
Mailing Address - Phone:262-544-0171
Mailing Address - Fax:
Practice Address - Street 1:3228 TURNBERRY OAK DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3969
Practice Address - Country:US
Practice Address - Phone:262-544-0171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEPPING STONE DENTAL PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental