Healthcare Provider Details

I. General information

NPI: 1609944644
Provider Name (Legal Business Name): ISTHMUS DENTAL, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 E JOHNSON ST
MADISON WI
53703-2120
US

IV. Provider business mailing address

122 E JOHNSON ST
MADISON WI
53703-2120
US

V. Phone/Fax

Practice location:
  • Phone: 608-257-0116
  • Fax:
Mailing address:
  • Phone: 608-257-0116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2469
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5551
License Number StateWI

VIII. Authorized Official

Name: JULIE THIES
Title or Position: BUSINESS MANAGER
Credential:
Phone: 608-257-0116