Healthcare Provider Details

I. General information

NPI: 1588249148
Provider Name (Legal Business Name): MEQUONCTD1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7604 W MEQUON RD
MEQUON WI
53097-3215
US

IV. Provider business mailing address

8025 EXCELSIOR DR STE 103
MADISON WI
53717-2902
US

V. Phone/Fax

Practice location:
  • Phone: 262-242-8929
  • Fax:
Mailing address:
  • Phone: 608-343-0818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MITCHELL WEILAND
Title or Position: ASSISTANT CONTROLLER
Credential:
Phone: 608-343-0818