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General NPI Number Information
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NPI Number | 1124573902
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Entity Type | Organization
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Legal Business Name | GREAT RIVER ORTHODONTIC SPECIALISTS, SC
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Dates
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Enumeration Date | 08/22/2016
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Last Update Date | 08/22/2016
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Provider Practice Location Address
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Address Line | 1200 MAIN ST
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City | LA CROSSE
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State | WI
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Zip | 54601-4468
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Country | US
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Telephone | 608-782-6778
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Fax |
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Provider Business Mailing Address
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Address Line | 3902 OAKWOOD HILLS PKWY
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City | EAU CLAIRE
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State | WI
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Zip | 54701-7780
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Country | US
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Telephone | 715-835-5182
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | BRENDA SAWYER
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Credential |
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Telephone | 715-835-5182
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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 | 1001026
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License Number State | WI
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