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General NPI Number Information
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NPI Number | 1124689914
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Entity Type | Organization
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Legal Business Name | MDC CASTLE ROCK
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Dates
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Enumeration Date | 06/24/2019
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Last Update Date | 06/24/2019
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Provider Practice Location Address
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Address Line | 205 DIVISION ST
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City | MAUSTON
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State | WI
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Zip | 53948-2109
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Country | US
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Telephone | 608-847-5572
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1658
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City | FOND DU LAC
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State | WI
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Zip | 54936-1658
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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 | CFO
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Name | BERNARD BOLKA
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Credential |
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Telephone | 920-579-3188
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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