Healthcare Provider Details

I. General information

NPI: 1578832853
Provider Name (Legal Business Name): EAU CLAIRE PERIODONTICS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 HEIGHTS DR STE 2C
EAU CLAIRE WI
54701-6146
US

IV. Provider business mailing address

2125 HEIGHTS DR STE 2C
EAU CLAIRE WI
54701-6146
US

V. Phone/Fax

Practice location:
  • Phone: 715-832-5396
  • Fax: 715-832-3009
Mailing address:
  • Phone: 715-832-5396
  • Fax: 715-832-3009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6810-015
License Number StateWI

VIII. Authorized Official

Name: DR. JASON D. JOHNSON
Title or Position: CHIEF MANAGER/PERIODONTIST
Credential: D.D.S., M.S.
Phone: 715-832-5396