Healthcare Provider Details

I. General information

NPI: 1841874930
Provider Name (Legal Business Name): LOREAL DOLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

IV. Provider business mailing address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

V. Phone/Fax

Practice location:
  • Phone: 262-836-5533
  • Fax:
Mailing address:
  • Phone: 262-334-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number81567-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: