Provider Demographics
NPI:1437289006
Name:WISCONSIN DENTAL GROUP, S.C.
Entity Type:Organization
Organization Name:WISCONSIN DENTAL GROUP, S.C.
Other - Org Name:FORWARDDENTAL KENOSHA
Other - Org Type:Doing Business As
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 1:3715 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1629
Mailing Address - Country:US
Mailing Address - Phone:414-351-6010
Mailing Address - Fax:414-351-6148
Practice Address - Street 1:3620 57TH AVE STE 600
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-4925
Practice Address - Country:US
Practice Address - Phone:414-351-6010
Practice Address - Fax:414-351-6148
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN DENTAL GROUP, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-06
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty