Provider Demographics
NPI:1417740465
Name:WISCONSIN ORAL MEDICINE LLC
Entity type:Organization
Organization Name:WISCONSIN ORAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BHAVIK
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-255-8743
Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-858-4125
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:8405 W FOREST HOME AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3407
Practice Address - Country:US
Practice Address - Phone:443-255-8743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty