Provider Demographics
NPI:1467582833
Name:WISCONSIN DENTAL GROUP,S.C.
Entity Type:Organization
Organization Name:WISCONSIN DENTAL GROUP,S.C.
Other - Org Name:FORWARD DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-357-2040
Mailing Address - Street 1:9052 N DEERBROOK TRL
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-2474
Mailing Address - Country:US
Mailing Address - Phone:414-357-2040
Mailing Address - Fax:414-354-3177
Practice Address - Street 1:9052 N DEERBROOK TRL
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-2474
Practice Address - Country:US
Practice Address - Phone:414-357-2040
Practice Address - Fax:414-354-3177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty