Healthcare Provider Details

I. General information

NPI: 1285976167
Provider Name (Legal Business Name): MDC OMRO, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1771 E MAIN ST
OMRO WI
54963-1594
US

IV. Provider business mailing address

101 CAMELOT DR STE 3
FOND DU LAC WI
54935-8048
US

V. Phone/Fax

Practice location:
  • Phone: 920-685-2121
  • Fax:
Mailing address:
  • Phone: 920-579-3188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. WILLIAM MAUTHE III
Title or Position: OWNER
Credential: D.D.S.
Phone: 920-948-6407