Kenosha Oral Surgery, S.C.

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

4998015 Issued in WI

Legal business name

KENOSHA ORAL SURGERY, S.C.

Practice address

6707 39TH Ave
Kenosha, WI 53142-7125

Phone

(262) 658-3559

Fax

(262) 658-0276

NPI assigned

Dec 17, 2007

Organization subpart

No

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

Authorized official

Name

Dr. Dale Willoughby, DDSNPI 1700880556

Title

President

Phone

(262) 658-3559

Specialties & licenses 1

Addresses

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Dale Wayne Willoughby, DDS

  • Oral and Maxillofacial Surgery (Dentist)
  • Kenosha, WI
  • NPI 1700880556
  NPD Authorized official
• Mark J. Buratti, D.D.S.

  • Endodontics
  • Kenosha, WI
  • NPI 1881717890
  NPD (past)
• James K. Kreutzer, D.D.S.

  • Endodontics
  • Kenosha, WI
  • NPI 1518080522
  NPD (past)

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

{
    "created_epoch": "1197849600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1654128000000",
    "number": "1710160486",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4707 WASHINGTON RD",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531441597",
            "telephone_number": "262-658-3559",
            "fax_number": "262-658-0276"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6707 39TH AVE",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531427125",
            "telephone_number": "262-658-3559",
            "fax_number": "262-658-0276"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KENOSHA ORAL SURGERY, S.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-17",
        "last_updated": "2022-06-02",
        "certification_date": "2022-06-02",
        "status": "A",
        "authorized_official_last_name": "WILLOUGHBY",
        "authorized_official_first_name": "DALE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "262-658-3559",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "WI",
            "license": "4998015",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kenosha Hand & Plastic Surgery SC
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• Kenosha Human Development Services, Inc
• Kenosha Kidney Dialysis LLC
• Kenosha Pain Center LLC
• Kenosha Pathology Consultants
• Kenosha Radiology Center LLC.
• Kenosha Senior Living, Inc.
• Kenosha Shuttle LLC

• Oral and Maxillofacial Surgery (Dentist) in Kenosha, WI
• Providers in Kenosha, WI by specialty
• Oral and Maxillofacial Surgery (Dentist) in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 2022; 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.