1013409002 NPI number — WISCONSIN ORAL & MAXILLOFACIAL SURGERY LLC

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 1013409002 NPI number — WISCONSIN ORAL & MAXILLOFACIAL SURGERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISCONSIN ORAL & MAXILLOFACIAL SURGERY LLC
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:
WHITE OAK DENTAL
Provider Other Organization Name Type Code:
3
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:
1013409002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 LEGEND WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALES
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53183-9539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-325-5672
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2603 W RAWSON AVE STE 123
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK CREEK
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53154-8422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-325-5672
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ALALAWI
Authorized Official First Name:
EJLAL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
914-325-5672

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QS0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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