Organization
KENOSHA ORAL SURGERY, S.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DALE WILLOUGHBY DDS (PRESIDENT)
(262) 658-3559
Entity
Organization
Contact information
Practice address
6707 39TH AVE, KENOSHA, WI 53142-7125
(262) 658-3559
(262) 658-0276
Mailing address
4707 WASHINGTON RD, KENOSHA, WI 53144-1597
(262) 658-3559
(262) 658-0276
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
4998015
WI
Other
Enumeration date
12/17/2007
Last updated
06/02/2022
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