Healthcare Provider Details

I. General information

NPI: 1467890475
Provider Name (Legal Business Name): DEREK B NORDEEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 NATIONAL DR STE 102
ONALASKA WI
54650-6709
US

IV. Provider business mailing address

2700 NATIONAL DR STE 102
ONALASKA WI
54650-6709
US

V. Phone/Fax

Practice location:
  • Phone: 608-783-3636
  • Fax: 608-783-3639
Mailing address:
  • Phone: 608-783-3636
  • Fax: 608-783-3639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number5311-0015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: