Healthcare Provider Details

I. General information

NPI: 1881969384
Provider Name (Legal Business Name): QUIRT FAMILY DENTISTRY, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S 3RD AVE
EDGAR WI
54426-9282
US

IV. Provider business mailing address

107 S 3RD AVE
EDGAR WI
54426-9282
US

V. Phone/Fax

Practice location:
  • Phone: 715-352-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KIM WILSON
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-5170