NPIMap

Organization Active NPI

Port Dental Group SC

  • General Practice Dentistry
  • Port Washington, WI
National Provider Identifier
1801913173
Registry record updated Jul 6, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
4635 Issued in WI
Legal business name
PORT DENTAL GROUP SC
Practice address
1000 N Wisconsin St
Port Washington, WI 53074-1285
Phone
(262) 284-9767
Fax
(262) 284-5228
NPI assigned
Mar 23, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 6, 2020

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

Authorized official

Name
Ms. Samone Aroonsavath
Title
Office Manager
Phone
(262) 284-9767

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X 4635 WI Primary
Customized Equipment (DME) 332BC3200X

Addresses

Primary practice location

1000 N Wisconsin St
Port Washington, WI 53074-1285

Mailing address

1000 N Wisconsin St
Port Washington, WI 53074-1285
Phone (262) 284-9767

Other identifiers 1

IdentifierTypeStateIssuer
33723100MedicaidWI

Other names 1

  • PORT DENTAL Other name

National Provider Directory

National Provider Directory

Locations

1000 N Wisconsin St
Port Washington, WI 53074
Phone (262) 284-7246

Practitioners & affiliated clinicians

Practitioners 1

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

NPI Registry JSON

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

{
    "created_epoch": "1174608000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1593993600000",
    "number": "1801913173",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1000 N WISCONSIN ST",
            "city": "PORT WASHINGTON",
            "state": "WI",
            "postal_code": "530741285",
            "telephone_number": "262-284-9767",
            "fax_number": "262-284-5228"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1000 N WISCONSIN ST",
            "city": "PORT WASHINGTON",
            "state": "WI",
            "postal_code": "530741285",
            "telephone_number": "262-284-9767",
            "fax_number": "262-284-5228"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORT DENTAL GROUP SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-23",
        "last_updated": "2020-07-06",
        "certification_date": "2020-07-06",
        "status": "A",
        "authorized_official_last_name": "AROONSAVATH",
        "authorized_official_first_name": "SAMONE",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "262-284-9767",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "WI",
            "license": "4635",
            "primary": true
        },
        {
            "code": "332BC3200X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Customized Equipment",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33723100",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PORT DENTAL",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "PORT DENTAL",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Port Washington, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2020; 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.