Healthcare Provider Details

I. General information

NPI: 1699016618
Provider Name (Legal Business Name): RIVER TOWN DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2013
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 MCHUGH ROAD
HOLMEN WI
54636-9256
US

IV. Provider business mailing address

3143 STATE ROAD SUITE 100
LA CROSSE WI
54601-6964
US

V. Phone/Fax

Practice location:
  • Phone: 608-526-9300
  • Fax: 608-526-9310
Mailing address:
  • Phone: 608-788-0030
  • Fax: 608-788-7881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5048
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5215
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6223
License Number StateWI

VIII. Authorized Official

Name: JENNIFER E. SCHIFFER
Title or Position: DIRECTOR OF ADMINISTRATIVE OPERATIO
Credential:
Phone: 608-788-0030