Provider Demographics
NPI:1942450457
Name:WISCONSIN ENDODONTIC GROUP, S.C.
Entity Type:Organization
Organization Name:WISCONSIN ENDODONTIC GROUP, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:MARIE HANSEN
Authorized Official - Last Name:FERGUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-258-1500
Mailing Address - Street 1:2600 N. MAYFAIR RD.
Mailing Address - Street 2:STE 240
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-258-1500
Mailing Address - Fax:414-258-9353
Practice Address - Street 1:2600 N. MAYFAIR RD.
Practice Address - Street 2:STE 240
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-258-1500
Practice Address - Fax:414-258-9353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-22
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA50021223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty