Healthcare Provider Details

I. General information

NPI: 1104389097
Provider Name (Legal Business Name): MERCER DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5222 HWY 51 N
MERCER WI
54547
US

IV. Provider business mailing address

8796 BRUNSWICK RD
MINOCQUA WI
54548-9346
US

V. Phone/Fax

Practice location:
  • Phone: 715-476-3432
  • Fax:
Mailing address:
  • Phone: 715-439-5365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DEREK RASMUSSEN
Title or Position: MANAGER
Credential:
Phone: 715-439-5365