Healthcare Provider Details

I. General information

NPI: 1336581875
Provider Name (Legal Business Name): DHCSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W PROSPECT ST
THORP WI
54771-9303
US

IV. Provider business mailing address

PO BOX 305
THORP WI
54771-0305
US

V. Phone/Fax

Practice location:
  • Phone: 715-669-5620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: JOHN TESSENDORF
Title or Position: OWNER
Credential: DDS
Phone: 715-832-3100