Provider Demographics
NPI:1649382946
Name:WAUSHARA DENTAL ASSOCIATES S.C.
Entity Type:Organization
Organization Name:WAUSHARA DENTAL ASSOCIATES S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:K
Authorized Official - Last Name:BENNOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-787-3200
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-0509
Mailing Address - Country:US
Mailing Address - Phone:920-787-3200
Mailing Address - Fax:920-787-2541
Practice Address - Street 1:N2888 STATE ROAD 22
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-5265
Practice Address - Country:US
Practice Address - Phone:920-787-3200
Practice Address - Fax:920-787-2541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI76140Medicare ID - Type Unspecified