Provider Demographics
NPI:1669024667
Name:SMILE DOCTORS OF WISCONSIN, S.C.
Entity Type:Organization
Organization Name:SMILE DOCTORS OF WISCONSIN, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:D'ANDRIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-727-3131
Mailing Address - Street 1:295 SE INNER LOOP
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-2140
Mailing Address - Country:US
Mailing Address - Phone:254-727-3131
Mailing Address - Fax:
Practice Address - Street 1:1616 N RANDALL AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1118
Practice Address - Country:US
Practice Address - Phone:608-754-4998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty