Healthcare Provider Details

I. General information

NPI: 1174644298
Provider Name (Legal Business Name): TODD L NEEDHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 NORTHERN RD
APPLETON WI
54914-8753
US

IV. Provider business mailing address

2535 NORTHERN RD
APPLETON WI
54914-8753
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-3224
  • Fax: 920-731-2910
Mailing address:
  • Phone: 920-731-3224
  • Fax: 920-731-2910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number1514G
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: