Healthcare Provider Details

I. General information

NPI: 1225197460
Provider Name (Legal Business Name): JOHN E LUDWIGSEN DDS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 SOUTH BAYSHORE DRIVE
SISTER BAY WI
54234-9309
US

IV. Provider business mailing address

940 SOUTH BAYSHORE DRIVE
SISTER BAY WI
54234-9309
US

V. Phone/Fax

Practice location:
  • Phone: 920-854-6556
  • Fax: 920-854-6559
Mailing address:
  • Phone: 920-854-6556
  • Fax: 920-854-6559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5084015
License Number StateWI

VIII. Authorized Official

Name: DR. JOHN ERNEST LUDWIGSON
Title or Position: OWNER
Credential: DDS
Phone: 920-854-6556