Provider Demographics
NPI:1750747739
Name:WISCONSIN DENTAL PARTNERS, LLC
Entity type:Organization
Organization Name:WISCONSIN DENTAL PARTNERS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:T
Authorized Official - Last Name:FABIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-712-6320
Mailing Address - Street 1:6907 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-2767
Mailing Address - Country:US
Mailing Address - Phone:608-712-6320
Mailing Address - Fax:608-338-0681
Practice Address - Street 1:340 MAIN ST
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53530-1426
Practice Address - Country:US
Practice Address - Phone:608-776-2620
Practice Address - Fax:608-776-3988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental