Healthcare Provider Details

I. General information

NPI: 1760052047
Provider Name (Legal Business Name): TAYLOR SCHUBERT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 06/29/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W PARK AVE
KIEL WI
53042-1717
US

IV. Provider business mailing address

5283 BECHAUD BEACH DRIVE
FOND DU LAC WI
54935
US

V. Phone/Fax

Practice location:
  • Phone: 920-894-2626
  • Fax:
Mailing address:
  • Phone: 920-960-5212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1002547-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: