Provider Demographics
NPI:1750468732
Name:OMALLEY DENTISTRY SC
Entity Type:Organization
Organization Name:OMALLEY DENTISTRY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:OMALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-425-4005
Mailing Address - Street 1:8555 W FOREST HM AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228
Mailing Address - Country:US
Mailing Address - Phone:414-425-4005
Mailing Address - Fax:414-529-9777
Practice Address - Street 1:8555 W FOREST HM AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228
Practice Address - Country:US
Practice Address - Phone:414-425-4005
Practice Address - Fax:414-529-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3802122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty