1104207232 NPI number — DENTAL CARE PROVIDERS OF AMERICA

Table of content: (NPI 1104207232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104207232 NPI number — DENTAL CARE PROVIDERS OF AMERICA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL CARE PROVIDERS OF AMERICA
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:
6
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:
1104207232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 788
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENOSHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53141-0788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-842-2877
Provider Business Mailing Address Fax Number:
877-725-4332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3715 WASHINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53144-1629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-237-6238
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2015

Additional Information

Authorized Official

Authorized Official Last Name:
KISKER
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
RYAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
224-645-4929

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  1001058-15 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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