Provider Demographics
NPI:1235111535
Name:DENNIS G VINCENT M D S C
Entity Type:Organization
Organization Name:DENNIS G VINCENT M D S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:GALEN
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-827-3144
Mailing Address - Street 1:14555 W NATIONAL AVE
Mailing Address - Street 2:STE 175
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53157-4484
Mailing Address - Country:US
Mailing Address - Phone:262-827-3144
Mailing Address - Fax:262-827-3150
Practice Address - Street 1:14555 W NATIONAL AVE
Practice Address - Street 2:STE 175
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53157-4484
Practice Address - Country:US
Practice Address - Phone:262-827-3144
Practice Address - Fax:262-827-3150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29313 020208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31409900Medicaid
C72550Medicare UPIN
000068810Medicare ID - Type Unspecified
WI31409900Medicaid