Provider Demographics
NPI:1902975709
Name:THE DOWNTOWN DENTAL GROUP
Entity Type:Organization
Organization Name:THE DOWNTOWN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-278-6070
Mailing Address - Street 1:161 W WISCONSIN AVE
Mailing Address - Street 2:SUITE 5036
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2602
Mailing Address - Country:US
Mailing Address - Phone:414-278-6070
Mailing Address - Fax:414-278-6087
Practice Address - Street 1:161 W WISCONSIN AVE
Practice Address - Street 2:SUITE 5036
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-2602
Practice Address - Country:US
Practice Address - Phone:414-278-6070
Practice Address - Fax:414-278-6087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2736261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38373000Medicaid