Healthcare Provider Details

I. General information

NPI: 1942457932
Provider Name (Legal Business Name): CESA #11 RURAL HEALTH DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 OSTERMANN DR
TURTLE LAKE WI
54889-9191
US

IV. Provider business mailing address

225 OSTERMANN DR
TURTLE LAKE WI
54889-9191
US

V. Phone/Fax

Practice location:
  • Phone: 715-986-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number6752-016
License Number StateWI

VIII. Authorized Official

Name: SHARON HAUGERUD
Title or Position: CLINIC DIRECTOR
Credential:
Phone: 715-986-2020