Healthcare Provider Details

I. General information

NPI: 1154909414
Provider Name (Legal Business Name): AREA DENTAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 BOUGHTON ST BLDG B
WATERTOWN WI
53094-3104
US

IV. Provider business mailing address

1149 BOUGHTON ST BLDG B
WATERTOWN WI
53094-3104
US

V. Phone/Fax

Practice location:
  • Phone: 920-261-0495
  • Fax: 920-261-3632
Mailing address:
  • Phone: 920-261-0495
  • Fax: 920-261-3632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARA STROHBUSCH
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 920-285-7441