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General NPI Number Information
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NPI Number | 1063563674
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Entity Type | Organization
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Legal Business Name | DOUGLAS D PODOLL DDS SC
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1460 10TH AVE
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City | BALDWIN
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State | WI
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Zip | 54002
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Country | US
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Telephone | 715-684-5858
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Fax | 715-684-5968
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Provider Business Mailing Address
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Address Line | 1460 10TH AVE PO BOX 516
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City | BALDWIN
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State | WI
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Zip | 54002
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Country | US
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Telephone | 715-684-5858
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Fax | 715-684-5968
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Authorized Official
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Title or Position | PRESIDENT
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Name | DOUGLAS D PODOLL
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Credential | DDS
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Telephone | 715-684-5858
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 3237
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License Number State | WI
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