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General NPI Number Information
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NPI Number | 1134408966
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Entity Type | Organization
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Legal Business Name | CLEARWATER DENTAL SC
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Dates
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Enumeration Date | 08/10/2011
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Last Update Date | 08/10/2011
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Provider Practice Location Address
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Address Line | 431 E CLAIREMONT AVE STE B
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City | EAU CLAIRE
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State | WI
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Zip | 54701-3685
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Country | US
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Telephone | 715-514-5300
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Fax | 715-514-5302
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Provider Business Mailing Address
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Address Line | 431 E CLAIREMONT AVE STE B
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City | EAU CLAIRE
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State | WI
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Zip | 54701-3685
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Country | US
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Telephone | 715-514-5300
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Fax | 715-514-5302
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. BOBBI S POTTER
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Credential |
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Telephone | 715-514-5300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 1697G
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License Number State | MN
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