Organization
DENTAL HAVEN FOR CHILDREN SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GONZALO E HERNANDEZ DDS (PRESIDENT)
(920) 739-6808
Entity
Organization
Contact information
Practice address
2612 E CALUMET ST, APPLETON, WI 54915-4104
(920) 739-6808
(888) 492-5007
Mailing address
2612 E CALUMET ST, APPLETON, WI 54915-4104
(920) 739-6808
(888) 492-5007
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
4564-015
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
33718600
—
WI
Enumeration date
07/03/2013
Last updated
03/07/2023
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