MEDICARE: BLACK BEAR DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1083575492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK BEAR DENTAL LLC

Provider Business Mailing Address
First Line	:	2901 PIONEER AVE
Second Line	:
City	:	RICE LAKE
State	:	WI
Zip	:	54868-2434
Country	:	US
Telephone Number	:	715-609-2461
Fax Number	:	920-626-6377

Provider Business Practice Location Address
First Line	:	2901 PIONEER AVE
Second Line	:
City	:	RICE LAKE
State	:	WI
Zip	:	54868-2434
Country	:	US
Telephone Number	:	715-609-2461
Fax Number	:	920-626-6377

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. JASON WILLIAM ISAACSON
Credential	:	DDS
Telephone Number	:	715-609-2461

Provider Enumeration Date	:	11/24/2025
Last Update Date	:	11/24/2025

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