Provider Demographics
NPI:1710160486
Name:KENOSHA ORAL SURGERY, S.C.
Entity Type:Organization
Organization Name:KENOSHA ORAL SURGERY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLOUGHBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-658-3559
Mailing Address - Street 1:4707 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1597
Mailing Address - Country:US
Mailing Address - Phone:262-658-3559
Mailing Address - Fax:262-658-0276
Practice Address - Street 1:6707 39TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7125
Practice Address - Country:US
Practice Address - Phone:262-658-3559
Practice Address - Fax:262-658-0276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49980151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty