Healthcare Provider Details

I. General information

NPI: 1720211345
Provider Name (Legal Business Name): LAURA MAE DOLFIN RD, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2009
Last Update Date: 08/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S BUSINESS PARK DR UNIT A-4
OOSTBURG WI
53070-1585
US

IV. Provider business mailing address

PO BOX 65
HINGHAM WI
53031-0065
US

V. Phone/Fax

Practice location:
  • Phone: 920-912-1007
  • Fax:
Mailing address:
  • Phone: 920-912-1007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2048-029
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: