Provider Demographics
NPI:1598105637
Name:DENTAL HAVEN FOR CHILDREN SC
Entity Type:Organization
Organization Name:DENTAL HAVEN FOR CHILDREN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:E
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-739-6808
Mailing Address - Street 1:2612 E CALUMET ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-4104
Mailing Address - Country:US
Mailing Address - Phone:920-739-6808
Mailing Address - Fax:888-492-5007
Practice Address - Street 1:2612 E CALUMET ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4104
Practice Address - Country:US
Practice Address - Phone:920-739-6808
Practice Address - Fax:888-492-5007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4564-0151223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33718600Medicaid
WI33718600Medicaid