Healthcare Provider Details

I. General information

NPI: 1841696127
Provider Name (Legal Business Name): EAU CLAIRE FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 REGIS CT
EAU CLAIRE WI
54701-4404
US

IV. Provider business mailing address

1018 REGIS CT
EAU CLAIRE WI
54701-4404
US

V. Phone/Fax

Practice location:
  • Phone: 715-832-8063
  • Fax: 715-835-1231
Mailing address:
  • Phone: 715-832-8063
  • Fax: 715-835-1231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2965
License Number StateWI

VIII. Authorized Official

Name: DR. NATHAN HENRY FLEMING
Title or Position: VICE PRESIDENT
Credential: DDS
Phone: 715-832-8063