Provider Demographics
NPI:1215388616
Name:ADVANCED ORTHODONTICS OF WISCONSIN
Entity Type:Organization
Organization Name:ADVANCED ORTHODONTICS OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOCHNOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:608-271-9293
Mailing Address - Street 1:5605 ODANA RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1207
Mailing Address - Country:US
Mailing Address - Phone:608-271-9293
Mailing Address - Fax:
Practice Address - Street 1:5605 ODANA RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1207
Practice Address - Country:US
Practice Address - Phone:608-271-9293
Practice Address - Fax:608-204-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty