Provider Demographics
NPI:1649492208
Name:PARADISE DENTAL PROFESSIONALS S.C.
Entity type:Organization
Organization Name:PARADISE DENTAL PROFESSIONALS S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:V
Authorized Official - Last Name:KATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-338-2992
Mailing Address - Street 1:1625 W PARADISE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095
Mailing Address - Country:US
Mailing Address - Phone:262-338-2992
Mailing Address - Fax:262-338-6032
Practice Address - Street 1:1625 W PARADISE DRIVE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095
Practice Address - Country:US
Practice Address - Phone:262-338-2992
Practice Address - Fax:262-338-6032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2788122300000X
WI2487122300000X
WI26081223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty