Provider Demographics
NPI:1972936508
Name:WISCO DENTAL, S.C.
Entity Type:Organization
Organization Name:WISCO DENTAL, S.C.
Other - Org Name:FOX VALLEY ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-725-1845
Mailing Address - Street 1:1155 WITTMANN DR
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-3607
Mailing Address - Country:US
Mailing Address - Phone:920-725-1845
Mailing Address - Fax:920-725-2805
Practice Address - Street 1:1155 WITTMANN DR
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-3607
Practice Address - Country:US
Practice Address - Phone:920-725-1845
Practice Address - Fax:920-725-2805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty