Healthcare Provider Details

I. General information

NPI: 1144132101
Provider Name (Legal Business Name): GRAND LINE DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 W CHURCH ST
EVANSVILLE WI
53536-1329
US

IV. Provider business mailing address

842 TWIN PINES DR
MADISON WI
53704-8560
US

V. Phone/Fax

Practice location:
  • Phone: 608-882-4860
  • Fax: 608-882-4862
Mailing address:
  • Phone: 715-297-6506
  • 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: MOAH KONG XIONG
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 715-297-6506