Provider Demographics
NPI:1245048925
Name:GLENDALE OPTIMAL DENTAL CARE, INC.
Entity type:Organization
Organization Name:GLENDALE OPTIMAL DENTAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IGWIKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-217-8236
Mailing Address - Street 1:6191 N GREEN BAY AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3813
Mailing Address - Country:US
Mailing Address - Phone:414-404-6464
Mailing Address - Fax:414-404-6499
Practice Address - Street 1:6191 N GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-3813
Practice Address - Country:US
Practice Address - Phone:414-404-6464
Practice Address - Fax:414-404-6499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty