Provider Demographics
NPI:1801941570
Name:RACINE DENTAL GROUP S C
Entity type:Organization
Organization Name:RACINE DENTAL GROUP S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HIPAA OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'LAUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-637-9371
Mailing Address - Street 1:1320 S GREENBAY RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4406
Mailing Address - Country:US
Mailing Address - Phone:262-637-9371
Mailing Address - Fax:262-619-7727
Practice Address - Street 1:1320 S GREENBAY RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4406
Practice Address - Country:US
Practice Address - Phone:262-637-9371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223G0001X, 1223P0221X, 1223P0300X, 1223S0112X, 1223X0400X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38393900Medicaid
WI=========Medicare UPIN