Healthcare Provider Details

I. General information

NPI: 1801019047
Provider Name (Legal Business Name): DINO J BORDINI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S TOWNLINE RD - BOX 1440
WAUTOMA WI
54982-1440
US

IV. Provider business mailing address

400 S TOWNLINE RD - BOX 1440
WAUTOMA WI
54982-1440
US

V. Phone/Fax

Practice location:
  • Phone: 920-787-5514
  • Fax:
Mailing address:
  • Phone: 920-787-5514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3133
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: