Healthcare Provider Details

I. General information

NPI: 1093814659
Provider Name (Legal Business Name): GENE RICHARD SORENSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 S MAIN ST
LODI WI
53555-1121
US

IV. Provider business mailing address

216 S MAIN ST
LODI WI
53555-1121
US

V. Phone/Fax

Practice location:
  • Phone: 608-592-4398
  • Fax: 608-592-5245
Mailing address:
  • Phone: 608-592-4398
  • Fax: 608-592-5245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5001592
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: