Provider Demographics
NPI:1013124056
Name:THE CENTER FOR DENTAL EXCELLENCE, S.C.
Entity Type:Organization
Organization Name:THE CENTER FOR DENTAL EXCELLENCE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-662-1440
Mailing Address - Street 1:410 SECURITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-9705
Mailing Address - Country:US
Mailing Address - Phone:920-662-1440
Mailing Address - Fax:920-662-1443
Practice Address - Street 1:410 SECURITY BLVD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-9705
Practice Address - Country:US
Practice Address - Phone:920-662-1440
Practice Address - Fax:920-662-1443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4498-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33797600Medicaid