Provider Demographics
NPI:1417549544
Name:DENTAL HEALTH PROFESSIONALS OF WISCONSIN, S.C.
Entity Type:Organization
Organization Name:DENTAL HEALTH PROFESSIONALS OF WISCONSIN, S.C.
Other - Org Name:KIND DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5699
Mailing Address - Street 1:4445 TAYLOR AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4445 TAYLOR AVE STE 1
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-4642
Practice Address - Country:US
Practice Address - Phone:262-554-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL HEALTH PROFESSIONALS OF WISCONSIN, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-10
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty