Healthcare Provider Details

I. General information

NPI: 1710468210
Provider Name (Legal Business Name): CLIFFSIDE DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 S BAY SHORE DR
SISTER BAY WI
54234-9160
US

IV. Provider business mailing address

2645 S BAY SHORE DR
SISTER BAY WI
54234-9160
US

V. Phone/Fax

Practice location:
  • Phone: 920-854-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN SLEDGE
Title or Position: MEMBER
Credential: DDS
Phone: 920-854-5200