MEDICARE: MT HOREB DENTAL

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	:	1871839779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MT HOREB DENTAL

Provider Business Mailing Address
First Line	:	303 E MAIN ST
Second Line	:	P.O. BOX 285
City	:	MOUNT HOREB
State	:	WI
Zip	:	53572-2032
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 E MAIN ST
Second Line	:
City	:	MOUNT HOREB
State	:	WI
Zip	:	53572-2032
Country	:	US
Telephone Number	:	608-437-5519
Fax Number	:

Authorized Official
Title or Position	:	CONTACT OFFICER
Name	:	GENIE KUBLE
Credential	:
Telephone Number	:	920-450-0157

Provider Enumeration Date	:	12/20/2012
Last Update Date	:	12/20/2012

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Directions to “MT HOREB DENTAL ” Practice Location

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