Healthcare Provider Details

I. General information

NPI: 1720777519
Provider Name (Legal Business Name): BETWEEN THE LAKES SLEEP AND AIRWAY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 06/25/2023
Certification Date: 06/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 TECKLA PL
KIEL WI
53042-9623
US

IV. Provider business mailing address

961 RIVER MEADOW DR
KIEL WI
53042-4851
US

V. Phone/Fax

Practice location:
  • Phone: 920-894-2305
  • Fax:
Mailing address:
  • Phone: 920-740-3427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. CONSTANCE ANNIE WALLANDER
Title or Position: DENTIST
Credential: DMD
Phone: 920-740-3427