# KENOSHA ORAL SURGERY, S.C.

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

## Provider details

- **NPI number:** 1710160486
- **Authorized official:** DR. DALE WILLOUGHBY DDS (PRESIDENT)
- **Authorized official phone:** (262) 658-3559

## Contact information

- **Practice address:** 6707 39TH AVE, KENOSHA, WI 53142-7125
- **Practice address phone:** (262) 658-3559
- **Practice address fax:** (262) 658-0276
- **Mailing address:** 4707 WASHINGTON RD, KENOSHA, WI 53144-1597
- **Mailing address phone:** (262) 658-3559
- **Mailing address fax:** (262) 658-0276

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 4998015 | WI | Yes |

## Other

- **Enumeration date:** 12/17/2007
- **Last updated:** 06/02/2022