Healthcare Provider Details

I. General information

NPI: 1144733510
Provider Name (Legal Business Name): EMBRACE WISCONSIN S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 11/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S MATTHIAS ST
APPLETON WI
54915-7229
US

IV. Provider business mailing address

2001 S MATTHIAS ST
APPLETON WI
54915-7229
US

V. Phone/Fax

Practice location:
  • Phone: 920-739-5822
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LYNN HIETPAS
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 920-739-5822