Provider Demographics
NPI:1659029171
Name:WISCONSIN DENTAL GROUP, S.C.
Entity Type:Organization
Organization Name:WISCONSIN DENTAL GROUP, S.C.
Other - Org Name:FORWARDDENTAL BROWN DEER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:7979 N SHERMAN BLVD # 200
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1776
Mailing Address - Country:US
Mailing Address - Phone:608-244-1440
Mailing Address - Fax:608-244-2372
Practice Address - Street 1:7979 N SHERMAN BLVD # 200
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-1776
Practice Address - Country:US
Practice Address - Phone:608-244-1440
Practice Address - Fax:608-244-2372
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN DENTAL GROUP, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-14
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty