Provider Demographics
NPI:1710330725
Name:MAJOR DENTAL CLINICS OF MILWAUKEE S.C.
Entity Type:Organization
Organization Name:MAJOR DENTAL CLINICS OF MILWAUKEE S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMAGALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:414-276-4262
Mailing Address - Street 1:788 N JEFFERSON ST
Mailing Address - Street 2:SUITE 880
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3718
Mailing Address - Country:US
Mailing Address - Phone:414-276-4262
Mailing Address - Fax:414-276-4269
Practice Address - Street 1:788 N JEFFERSON ST
Practice Address - Street 2:SUITE 880
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3718
Practice Address - Country:US
Practice Address - Phone:414-276-4262
Practice Address - Fax:414-276-4269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6468122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6468OtherLICENSE