ADVANCE DENTAL MANAGEMENT — NPI 1417020454 (Licensed Doctor of Dental Surgery (DDS) / Doctor of Medicine in Dentistry (DMD) in MUKWONAGO, WI)

CMS-1500 Box 24J / 33a • NPI

1417020454

Type 2 Organization (Box 32a/33a)

HIPAA NUCC Taxonomy • CMS Code

1223G0001X (CMS C5)

Licensed Doctor of Dental Surgery (DDS) / Doctor of Medicine in Dentistry (DMD)

Box 32 Service Location & ZIP+4

720 N ROCHESTER ST, SUITE 203, MUKWONAGO, WI, 53149-1188

✓ 9-Digit EDI 837 ZIP+4 (53149-1188)

Practice Phone & Referral Fax

(262) 363-2220

Fax: (262) 363-2221

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1417020454 (ADVANCE DENTAL MANAGEMENT) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

Institutional Type-2 NPI facilities enroll via CMS-855A institutional provider agreements rather than individual Order & Referring PECOS.

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1417020454` (NPI-2 Organization / Facility)
Provider / Legal Name	ADVANCE DENTAL MANAGEMENT
Plain-English Specialty	Licensed Doctor of Dental Surgery (DDS) / Doctor of Medicine in Dentistry (DMD) NUCC Code: `1223G0001X` (Dentist, General Practice)
Certifying / Licensing Body	American Dental Association (ADA) / State Board of Dental Examiners
Practice Location Address	720 N ROCHESTER ST, SUITE 203, MUKWONAGO, WI, 53149-1188
Practice Telephone / Fax	Tel: (262) 363-2220 \| Fax: (262) 363-2221
Administrative Mailing Address	720 N ROCHESTER ST, MUKWONAGO, WI, 53149-1188
Enumeration & Last Sync	Enumerated: 2006-11-16 \| CMS Record Updated: 2020-08-22
Authorized Official	GENIE KUBLE (Contact Officer)

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

720 N ROCHESTER ST, SUITE 203, MUKWONAGO, WI, 53149-1188

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Plain-English Taxonomy & CMS Crosswalk (1223G0001X)

What Does Taxonomy Code 1223G0001X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 1223G0001X translates to:
"Licensed Doctor of Dental Surgery (DDS) / Doctor of Medicine in Dentistry (DMD)"

CMS-1500 Medicare Specialty Crosswalk: CMS Code C5 (Dentist)
Certifying / Accrediting Authority: American Dental Association (ADA) / State Board of Dental Examiners
Clinical Scope: Routine 6-month dental checkups, toothache, dental abscess, bleeding gums (periodontitis), or wisdom tooth extraction.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (ADVANCE DENTAL MANAGEMENT)

Typical CPT / Diagnostic Procedures:

Comprehensive Oral Evaluation, Digital Dental Radiographs & Prophylaxis
Restorative Composite Fillings, Crowns, Endodontic Root Canal & Extractions

Common Therapeutic Classes:

Amoxicillin, Metronidazole & Clindamycin (Odontogenic Infections)
Chlorhexidine Gluconate 0.12% Oral Rinse & High-Fluoride Varnish

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`1223G0001X` — Dentist, General Practice Plain English: Licensed Doctor of Dental Surgery (DDS) / Doctor of Medicine in Dentistry (DMD)	State: WI \| License: `5000526` \| Primary: Yes (Primary)

Medical Billing, RCM & Hospital Credentialing Teams:

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ADVANCE DENTAL MANAGEMENT (NPI #1417020454)