Healthcare Provider Details

I. General information

NPI: 1962631952
Provider Name (Legal Business Name): SDC DENTAL HYGIENE CONCEPTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 07/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5135 GROVE RD
REEDSVILLE WI
54230-9182
US

IV. Provider business mailing address

5135 GROVE RD
REEDSVILLE WI
54230-9182
US

V. Phone/Fax

Practice location:
  • Phone: 920-242-2209
  • Fax:
Mailing address:
  • Phone: 920-242-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number6637-016
License Number StateWI

VIII. Authorized Official

Name: SARA ANN BEAUPRE
Title or Position: REGISTERED DENTAL HYGIENIST
Credential: RDH
Phone: 920-242-2209