Provider Demographics
NPI:1487211447
Name:RESTORATION DENTAL LLC
Entity Type:Organization
Organization Name:RESTORATION DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-732-8043
Mailing Address - Street 1:6373 N JEAN NICOLET RD STE 202
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4184
Mailing Address - Country:US
Mailing Address - Phone:414-228-9680
Mailing Address - Fax:
Practice Address - Street 1:6373 N JEAN NICOLET RD STE 202
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4184
Practice Address - Country:US
Practice Address - Phone:414-228-9680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-24
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental