Provider Demographics
NPI:1730184557
Name:NORTHRIDGE DENTAL CENTER S.C.
Entity type:Organization
Organization Name:NORTHRIDGE DENTAL CENTER S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FITCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-354-9020
Mailing Address - Street 1:2327 W APPLE TREE RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3311
Mailing Address - Country:US
Mailing Address - Phone:414-352-3839
Mailing Address - Fax:
Practice Address - Street 1:7906 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-3916
Practice Address - Country:US
Practice Address - Phone:414-354-9020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001515-015261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental