Healthcare Provider Details

I. General information

NPI: 1134898786
Provider Name (Legal Business Name): DELTA DENTAL OF WISCONSIN FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

941 MICHIGAN AVE
STEVENS POINT WI
54481
US

IV. Provider business mailing address

PO BOX 828
STEVENS POINT WI
54481-0828
US

V. Phone/Fax

Practice location:
  • Phone: 715-204-1180
  • Fax: 715-204-3901
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: ANN BOSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 715-343-7209