Healthcare Provider Details

I. General information

NPI: 1285974386
Provider Name (Legal Business Name): NORTHWOODS DENTAL SLEEP THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 N RAILROAD ST
EAGLE RIVER WI
54521-8834
US

IV. Provider business mailing address

865 N RAILROAD ST
EAGLE RIVER WI
54521-8834
US

V. Phone/Fax

Practice location:
  • Phone: 715-479-6100
  • Fax:
Mailing address:
  • Phone: 715-479-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5242-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. DARRIN J GREMBAN
Title or Position: OWNER
Credential: DDS
Phone: 715-479-6100