# THE KIDS DENTIST LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1407257108
- **Authorized official:** DR. SHANE FISHER DDS (OWNER)
- **Authorized official phone:** (262) 241-0400

## Contact information

- **Practice address:** 10618 N PORT WASHINGTON RD, MEQUON, WI 53092-5013
- **Practice address phone:** (262) 241-0400
- **Mailing address:** 10618 N PORT WASHINGTON RD, MEQUON, WI 53092-5013
- **Mailing address phone:** (262) 241-0400

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | 5127-015 | WI | Yes |

## Other

- **Enumeration date:** 09/12/2014
- **Last updated:** 09/12/2014