Provider Demographics
NPI:1710968086
Name:CHILDREN'S DENTAL HEALTH CENTER, S.C.
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL HEALTH CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEINMETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:920-731-2566
Mailing Address - Street 1:W3132 VAN ROY RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-3982
Mailing Address - Country:US
Mailing Address - Phone:920-731-2566
Mailing Address - Fax:920-731-7868
Practice Address - Street 1:W3132 VAN ROY RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-3982
Practice Address - Country:US
Practice Address - Phone:920-731-2566
Practice Address - Fax:920-731-7868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45861223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33570700Medicaid
WI33732800Medicaid
WI33744500Medicaid