Healthcare Provider Details

I. General information

NPI: 1649273285
Provider Name (Legal Business Name): ERIC TODD LOBERG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15397 STATE HIGHWAY 32
LAKEWOOD WI
54138-9702
US

IV. Provider business mailing address

1907 DEXTER ST
NEW LONDON WI
54961-2523
US

V. Phone/Fax

Practice location:
  • Phone: 715-276-6321
  • Fax: 715-276-1428
Mailing address:
  • Phone: 920-531-1479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5234-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: