Provider Demographics
NPI:1447390521
Name:CHILDREN'S DENTAL CLINIC, S.C.
Entity type:Organization
Organization Name:CHILDREN'S DENTAL CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BALBIR
Authorized Official - Middle Name:R
Authorized Official - Last Name:BAGGA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:414-744-3333
Mailing Address - Street 1:3612 TURNBERRY DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-6307
Mailing Address - Country:US
Mailing Address - Phone:414-744-3333
Mailing Address - Fax:414-744-1155
Practice Address - Street 1:3814 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-3841
Practice Address - Country:US
Practice Address - Phone:414-744-3333
Practice Address - Fax:414-744-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25451223G0001X, 1223P0221X
WI41461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI951942OtherUNITED CONCORDIA PROVIDER