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General NPI Number Information
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NPI Number | 1073754024
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Entity Type | Organization
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Legal Business Name | FOWLER MEMORIAL FREE DENTAL CLINIC
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Dates
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Enumeration Date | 03/19/2009
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Last Update Date | 03/19/2009
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Provider Practice Location Address
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Address Line | N3150 HIGHWAY 81 SUITE B-14
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City | MONROE
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State | WI
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Zip | 53566-9397
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Country | US
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Telephone | 608-328-9404
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Fax |
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Provider Business Mailing Address
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Address Line | N3150 HIGHWAY 81 SUITE B-14
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City | MONROE
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State | WI
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Zip | 53566-9397
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Country | US
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Telephone | 608-328-9404
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Fax |
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Authorized Official
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Title or Position | CLINIC COORDINATOR
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Name | ANNAMARIA BLIVEN
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Credential | M.A.
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Telephone | 608-558-2948
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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