Provider Demographics
NPI:1568435253
Name:DCP OF SOUTHRIDGE SHOPPING CENTER, LLC
Entity Type:Organization
Organization Name:DCP OF SOUTHRIDGE SHOPPING CENTER, LLC
Other - Org Name:DENTALWORKS OF GREENFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NITTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-755-0816
Mailing Address - Street 1:7160 NORTH DALLAS PARKWAY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7995 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-3710
Practice Address - Country:US
Practice Address - Phone:414-282-6583
Practice Address - Fax:216-584-1020
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTALONE PARTNERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-11
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty