Provider Demographics
NPI:1467059865
Name:WISCONSIN SMILES
Entity Type:Organization
Organization Name:WISCONSIN SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HIDAYATHULLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:224-766-9876
Mailing Address - Street 1:6719 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2041
Mailing Address - Country:US
Mailing Address - Phone:414-464-6300
Mailing Address - Fax:414-464-2874
Practice Address - Street 1:6719 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2041
Practice Address - Country:US
Practice Address - Phone:414-464-6300
Practice Address - Fax:414-464-2874
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN SMILES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1699128082OtherCMS-NPI