Healthcare Provider Details

I. General information

NPI: 1386636959
Provider Name (Legal Business Name): DENTAL PARK SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 RANDOLPH CT
MANITOWOC WI
54220-8345
US

IV. Provider business mailing address

1503 RANDOLPH CT
MANITOWOC WI
54220-8345
US

V. Phone/Fax

Practice location:
  • Phone: 920-682-0321
  • Fax: 920-682-3128
Mailing address:
  • Phone: 920-682-0321
  • Fax: 920-682-3128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateWI

VIII. Authorized Official

Name: DR. DANIEL ROBERT BOETTCHER
Title or Position: PARTNER SECRETARY
Credential: DDS
Phone: 920-682-0321