Healthcare Provider Details

I. General information

NPI: 1992890198
Provider Name (Legal Business Name): VALLEY ENDODONTICS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N LYNNDALE DRIVE
APPLETON WI
54914
US

IV. Provider business mailing address

1100 N LYNNDALE DRIVE
APPLETON WI
54914
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-4484
  • Fax: 920-731-2889
Mailing address:
  • Phone: 920-731-4484
  • Fax: 920-731-2889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. STARR WILLIAM CLARK
Title or Position: ENDODONTIST PARTNER
Credential: DDS
Phone: 920-731-4484