Healthcare Provider Details

I. General information

NPI: 1629224852
Provider Name (Legal Business Name): DENTAL ASSOCIATES OF LAKE MILLS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E TYRANENA PARK RD
LAKE MILLS WI
53551-9681
US

IV. Provider business mailing address

311 E TYRANENA PARK RD
LAKE MILLS WI
53551-9681
US

V. Phone/Fax

Practice location:
  • Phone: 920-648-2331
  • Fax: 920-648-3437
Mailing address:
  • Phone: 920-648-2331
  • Fax: 920-648-3437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3647
License Number StateWI

VIII. Authorized Official

Name: DIANE M. SCHLEICHER
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 920-648-2331