Provider Demographics
NPI:1245742733
Name:D2 DENTAL OF WISCONSIN, S.C.
Entity Type:Organization
Organization Name:D2 DENTAL OF WISCONSIN, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LABINOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-613-4542
Mailing Address - Street 1:137 N OAK PARK AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1838 S 15TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3225
Practice Address - Country:US
Practice Address - Phone:414-455-8805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty