Healthcare Provider Details

I. General information

NPI: 1316954928
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY ASSO OF EAU CLAIRE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 OAKLEAF WAY
ALTOONA WI
54720
US

IV. Provider business mailing address

1120 OAK RIDGE DRIVE
EAU CLAIRE WI
54701
US

V. Phone/Fax

Practice location:
  • Phone: 715-834-8414
  • Fax: 715-834-3557
Mailing address:
  • Phone: 715-834-8414
  • Fax: 715-834-3557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number4680-015
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number5112-015
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number5563-015
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6222-15
License Number StateWI
# 6
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4412-015
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number4495-015
License Number StateWI

VIII. Authorized Official

Name: GINA K THOR
Title or Position: TRANSCRIPTION AND CREDENTIALING
Credential:
Phone: 715-834-8414