Provider Demographics
NPI:1710900808
Name:CENTER FOR ORAL & MAXILLOFACIAL SURGERY SC
Entity Type:Organization
Organization Name:CENTER FOR ORAL & MAXILLOFACIAL SURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:S CORP PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SWEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-833-2060
Mailing Address - Street 1:20 S PARK ST #506
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715
Mailing Address - Country:US
Mailing Address - Phone:608-256-1961
Mailing Address - Fax:608-256-1501
Practice Address - Street 1:7007 OLD SAUK RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713
Practice Address - Country:US
Practice Address - Phone:608-833-2060
Practice Address - Fax:608-833-1737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38390400Medicaid
WI79095Medicare ID - Type Unspecified