Provider Demographics
NPI:1154459881
Name:WISCONSIN DENTAL GROUP, S.C.
Entity Type:Organization
Organization Name:WISCONSIN DENTAL GROUP, S.C.
Other - Org Name:FORWARDDENTAL APPLETON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:3030 N BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8707
Mailing Address - Country:US
Mailing Address - Phone:414-963-2301
Mailing Address - Fax:414-963-0413
Practice Address - Street 1:3030 N BALLARD RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8707
Practice Address - Country:US
Practice Address - Phone:414-963-2301
Practice Address - Fax:414-963-0413
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN DENTAL GROUP, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-02
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty