Healthcare Provider Details

I. General information

NPI: 1336237551
Provider Name (Legal Business Name): TRI-COUNTY COMMUNITY DENTAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 TRI PARK WAY
APPLETON WI
54914-1661
US

IV. Provider business mailing address

9 TRI PARK WAY
APPLETON WI
54914-1661
US

V. Phone/Fax

Practice location:
  • Phone: 920-882-9989
  • Fax: 920-882-9961
Mailing address:
  • Phone: 920-882-9989
  • Fax: 920-882-9961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SANDY DREXLER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 920-882-9989