Provider Demographics
NPI:1710478557
Name:GLENDALE DENTAL LLC
Entity Type:Organization
Organization Name:GLENDALE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:POTRYKUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-646-2771
Mailing Address - Street 1:920 INDIAN SPRING DR
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2242
Mailing Address - Country:US
Mailing Address - Phone:262-873-0510
Mailing Address - Fax:
Practice Address - Street 1:5150 N PORT WASHINGTON RD STE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5400
Practice Address - Country:US
Practice Address - Phone:414-964-8850
Practice Address - Fax:414-964-8918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6886261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental