# WISCONSIN DENTAL GROUP, S.C.

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** WISCONSIN DENTAL GROUP, S.C.
- **Other names:** ForwardDental Glendale
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1265562631
- **Legal business name:** WISCONSIN DENTAL GROUP, S.C.
- **Authorized official:** CELIA HAYES (CREDENTIALING COORDINATOR)
- **Authorized official phone:** (217) 540-2100

## Contact information

- **Practice address:** 7040 N PORT WASHINGTON RD STE 414, GLENDALE, WI 53217-3885
- **Practice address phone:** (920) 212-4641
- **Practice address fax:** (920) 954-9080
- **Mailing address:** 7040 N PORT WASHINGTON RD STE 414, GLENDALE, WI 53217-3885
- **Mailing address phone:** (920) 212-4641
- **Mailing address fax:** (920) 954-9080

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | — | NULL | Yes |
| 1223P0221X | Pediatric Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 03/06/2007
- **Last updated:** 04/15/2022