Provider Demographics
NPI:1760538490
Name:WISCONSIN ORAL SURGERY & DENTAL IMPLANTS, S.C.
Entity Type:Organization
Organization Name:WISCONSIN ORAL SURGERY & DENTAL IMPLANTS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAGONESE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-327-4130
Mailing Address - Street 1:10401 W LINCOLN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1255
Mailing Address - Country:US
Mailing Address - Phone:414-327-4130
Mailing Address - Fax:414-327-4218
Practice Address - Street 1:10401 W LINCOLN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1255
Practice Address - Country:US
Practice Address - Phone:414-327-4130
Practice Address - Fax:414-327-4218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5420-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33795900Medicaid
WI33795900Medicaid
WI1649350398Medicare PIN