NPIMap

Organization Active NPI

MDC West Bend, LLC

  • Dentist
  • West Bend, WI
National Provider Identifier
1497294722
Registry record updated Feb 20, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
5479015 Issued in WI
Legal business name
MDC WEST BEND, LLC
Practice address
1625 W Paradise Dr
West Bend, WI 53095-7846
Phone
(262) 338-2992
NPI assigned
Feb 20, 2017
Last updated
Feb 20, 2017By the provider in NPPES
Organization subpart
Yes
Parent organization
MODERN DENTAL CARE HOLDINGS, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 20, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Bernard Bolka IV
Title
Member
Phone
(920) 579-3188

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X 5479015 WI Primary

Addresses

Primary practice location

1625 W Paradise Dr
West Bend, WI 53095-7846

Mailing address

7 Sheboygan St
Fond Du Lac, WI 54935-4281
Phone (920) 579-3188

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1487548800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1487548800000",
    "number": "1497294722",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7 SHEBOYGAN ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354281",
            "telephone_number": "920-579-3188"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1625 W PARADISE DR",
            "city": "WEST BEND",
            "state": "WI",
            "postal_code": "530957846",
            "telephone_number": "262-338-2992"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MDC WEST BEND, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MODERN DENTAL CARE HOLDINGS, LLC",
        "enumeration_date": "2017-02-20",
        "last_updated": "2017-02-20",
        "status": "A",
        "authorized_official_last_name": "BOLKA",
        "authorized_official_first_name": "BERNARD",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "920-579-3188",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "IV"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "WI",
            "license": "5479015",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in West Bend, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 20, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.