1124168638 NPI number — WAUKESHA PEDIATRIC DENTAL CARE SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124168638 NPI number — WAUKESHA PEDIATRIC DENTAL CARE SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAUKESHA PEDIATRIC DENTAL CARE SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124168638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2727 N GRANDVIEW BLVD
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
WAUKESHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53188-1671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-542-8402
Provider Business Mailing Address Fax Number:
262-542-4436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2727 N GRANDVIEW BLVD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
WAUKESHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53188-1671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-542-8402
Provider Business Practice Location Address Fax Number:
262-542-4436
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NORWICK
Authorized Official First Name:
SUSANN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
DR CEO
Authorized Official Telephone Number:
262-542-8402

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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