Provider Demographics
NPI:1609493188
Name:WILLOW DENTAL GROUP LLC
Entity Type:Organization
Organization Name:WILLOW DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-505-1000
Mailing Address - Street 1:3333 S SUNNYSLOPE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-4504
Mailing Address - Country:US
Mailing Address - Phone:262-505-1000
Mailing Address - Fax:
Practice Address - Street 1:3333 S SUNNYSLOPE RD STE 100
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4504
Practice Address - Country:US
Practice Address - Phone:262-505-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental