Provider Demographics
NPI:1982385944
Name:WATERFORD CHILDRENS DENTISTRY SC
Entity Type:Organization
Organization Name:WATERFORD CHILDRENS DENTISTRY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRADY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:414-350-0945
Mailing Address - Street 1:790 CORNERSTONE XING
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-4582
Mailing Address - Country:US
Mailing Address - Phone:414-350-0945
Mailing Address - Fax:
Practice Address - Street 1:790 CORNERSTONE XING
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-4582
Practice Address - Country:US
Practice Address - Phone:414-350-0945
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARAMOUNT PEDIATRIC DENTISTRY SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty