Healthcare Provider Details

I. General information

NPI: 1649849696
Provider Name (Legal Business Name): APPLETON DENTAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 W COLLEGE AVE
APPLETON WI
54914-4201
US

IV. Provider business mailing address

2640 W COLLEGE AVE
APPLETON WI
54914-4201
US

V. Phone/Fax

Practice location:
  • Phone: 312-539-0575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: SYED REHMAN
Title or Position: OWNER
Credential: DMD
Phone: 312-539-0575