Provider Demographics
NPI:1932445442
Name:NORTH SHORE DENTAL, LLC
Entity Type:Organization
Organization Name:NORTH SHORE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-242-1180
Mailing Address - Street 1:1345 W TOWNE SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5047
Mailing Address - Country:US
Mailing Address - Phone:262-242-1180
Mailing Address - Fax:262-236-9079
Practice Address - Street 1:1345 W TOWNE SQUARE RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5047
Practice Address - Country:US
Practice Address - Phone:262-242-1180
Practice Address - Fax:262-236-9079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5426-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty