Organization
PORT DENTAL GROUP SC
Active
Other names
PORT DENTAL
Organization subpart
No
Provider details
NPI number
Authorized official
MS. SAMONE AROONSAVATH (OFFICE MANAGER)
(262) 284-9767
Entity
Organization
Contact information
Practice address
1000 N WISCONSIN ST, PORT WASHINGTON, WI 53074-1285
(262) 284-9767
(262) 284-5228
Mailing address
1000 N WISCONSIN ST, PORT WASHINGTON, WI 53074-1285
(262) 284-9767
(262) 284-5228
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
4635
WI
332BC3200X
Customized Equipment (DME)
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
33723100
—
WI
Enumeration date
03/23/2007
Last updated
07/06/2020
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