Provider Demographics
NPI:1578856225
Name:PARKWAY DENTAL, S.C.
Entity Type:Organization
Organization Name:PARKWAY DENTAL, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIELMA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-649-3510
Mailing Address - Street 1:2901 W KINNICKINNIC RIVER PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3660
Mailing Address - Country:US
Mailing Address - Phone:414-649-3510
Mailing Address - Fax:414-385-2854
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY STE 104
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3660
Practice Address - Country:US
Practice Address - Phone:414-649-3510
Practice Address - Fax:414-385-2854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50016561223G0001X
WI50031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty