=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225141831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY BERNADETTE HOVEL DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3511 EAST AVE SO
-----------------------------------------------------
City | LACROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-788-2016
-----------------------------------------------------
Fax | 608-788-2087
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3511 EAST AVE SO
-----------------------------------------------------
City | LACROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-788-2016
-----------------------------------------------------
Fax | 608-788-2087
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3491
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------