Provider Demographics
NPI:1659744506
Name:DENTAL CASTLE INC
Entity Type:Organization
Organization Name:DENTAL CASTLE INC
Other - Org Name:SWAN DENTAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHSHOUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-258-2216
Mailing Address - Street 1:2669 N SWAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1800
Mailing Address - Country:US
Mailing Address - Phone:414-258-2216
Mailing Address - Fax:414-258-9466
Practice Address - Street 1:2669 N SWAN BLVD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1800
Practice Address - Country:US
Practice Address - Phone:414-258-2216
Practice Address - Fax:414-258-9466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-01
Last Update Date:2015-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI019029338122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty