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General NPI Number Information
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NPI Number | 1265605265
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Entity Type | Organization
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Legal Business Name | WESTERN WISCONSIN ORAL HEALTH INITIATIVE
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Dates
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Enumeration Date | 04/10/2008
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Last Update Date | 04/10/2008
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Provider Practice Location Address
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Address Line | 1300 BADGER ST HEALTH SCIENCE CENTER
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City | LA CROSSE
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State | WI
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Zip | 54601-1502
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Country | US
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Telephone | 608-789-6101
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Fax |
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Provider Business Mailing Address
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Address Line | 304 6TH ST N
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City | LA CROSSE
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State | WI
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Zip | 54601-3342
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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 | PROGRAM HEAD
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Name | BARBARA L JERUE
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Credential | RDH
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Telephone | 608-785-9843
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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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