Healthcare Provider Details

I. General information

NPI: 1679553093
Provider Name (Legal Business Name): NORTHSTAR DENTAL GRP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5760 GRANDE MARKET DR
APPLETON WI
54913
US

IV. Provider business mailing address

5760 GRAND MARKET DR
APPLETON WI
54913
US

V. Phone/Fax

Practice location:
  • Phone: 920-997-1557
  • Fax: 920-997-0688
Mailing address:
  • Phone: 920-997-1557
  • Fax: 920-997-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER D HEHLI
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 920-997-1557