Healthcare Provider Details

I. General information

NPI: 1285124024
Provider Name (Legal Business Name): SMILE CLINIC - MANITOWOC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N 18TH ST
MANITOWOC WI
54220-1858
US

IV. Provider business mailing address

4607 ROYAL DR
EAU CLAIRE WI
54701-2928
US

V. Phone/Fax

Practice location:
  • Phone: 920-682-9231
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TODD HEHLI
Title or Position: OWNER
Credential:
Phone: 715-833-8755