Provider Demographics
NPI:1174638142
Name:PROGRESSIVE PEDIATRIC DENTIST SC
Entity Type:Organization
Organization Name:PROGRESSIVE PEDIATRIC DENTIST SC
Other - Org Name:STEVEN CHYBOWSKI
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CHYBOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-768-1020
Mailing Address - Street 1:8375 S HOWELL AVE
Mailing Address - Street 2:#201
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-8344
Mailing Address - Country:US
Mailing Address - Phone:414-768-1020
Mailing Address - Fax:414-768-8866
Practice Address - Street 1:8375 S HOWELL AVE
Practice Address - Street 2:#201
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8344
Practice Address - Country:US
Practice Address - Phone:414-768-1020
Practice Address - Fax:414-768-8866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38393100Medicaid