Provider Demographics
NPI:1952431090
Name:WISCONSIN DENTAL GROUP, S.C.
Entity Type:Organization
Organization Name:WISCONSIN DENTAL GROUP, S.C.
Other - Org Name:FORWARDDENTAL NEW BERLIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:15100 LIBRARY LN
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5291
Mailing Address - Country:US
Mailing Address - Phone:262-641-0056
Mailing Address - Fax:262-641-0058
Practice Address - Street 1:15100 LIBRARY LN
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5291
Practice Address - Country:US
Practice Address - Phone:262-641-0056
Practice Address - Fax:262-641-0058
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN DENTAL GROUP, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-07
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty