Provider Demographics
NPI:1417605312
Name:ADVANCED DENTAL SPECIALISTS, LLC
Entity Type:Organization
Organization Name:ADVANCED DENTAL SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:6218 WASHINGTON AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3916
Mailing Address - Country:US
Mailing Address - Phone:262-465-4232
Mailing Address - Fax:262-465-4562
Practice Address - Street 1:6218 WASHINGTON AVE STE C
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-3916
Practice Address - Country:US
Practice Address - Phone:262-465-4232
Practice Address - Fax:262-465-4562
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DENTAL SPECIALISTS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty