Provider Demographics
NPI:1689942195
Name:SMILE WISCONSIN LTD
Entity Type:Organization
Organization Name:SMILE WISCONSIN LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SOLOMON
Authorized Official - Middle Name:K
Authorized Official - Last Name:PESIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:888-833-8441
Mailing Address - Street 1:33533 W 12 MILE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3354
Mailing Address - Country:US
Mailing Address - Phone:888-833-8441
Mailing Address - Fax:888-330-4331
Practice Address - Street 1:250 E WISCONSIN AVE
Practice Address - Street 2:SUITE 1800
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-4232
Practice Address - Country:US
Practice Address - Phone:888-833-8441
Practice Address - Fax:888-330-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6817-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty