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General NPI Number Information
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NPI Number | 1114230968
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Entity Type | Organization
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Legal Business Name | TWIN PORTS DENTAL
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Dates
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Enumeration Date | 07/22/2010
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Last Update Date | 07/22/2010
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Provider Practice Location Address
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Address Line | 1507 TOWER AVE ROOM 427
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City | SUPERIOR
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State | WI
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Zip | 54880-2532
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Country | US
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Telephone | 715-394-5792
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Fax |
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Provider Business Mailing Address
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Address Line | 1507 TOWER AVE ROOM 427
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City | SUPERIOR
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State | WI
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Zip | 54880-2532
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CONTACT OFFICER
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Name | GENIE KUBLE
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Credential |
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Telephone | 920-450-0157
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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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