Provider Demographics
NPI:1437219417
Name:DENTISTRY OF WISCONSIN
Entity Type:Organization
Organization Name:DENTISTRY OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:AMSTADT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-834-6321
Mailing Address - Street 1:1260 W MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-1930
Mailing Address - Country:US
Mailing Address - Phone:608-834-8668
Mailing Address - Fax:
Practice Address - Street 1:1260 W MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1930
Practice Address - Country:US
Practice Address - Phone:608-834-8668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty