=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295877363
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN SCALETTA D.D.S.LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 WEST FIFTH ST.
-----------------------------------------------------
City | NEILLSVILLE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54456-0067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-743-3293
-----------------------------------------------------
Fax | 715-743-3294
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N1005 RESEWOOD AVE
-----------------------------------------------------
City | NEILLSVILLE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54456-6627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-743-7792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN A. SCALETTA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 715-743-7792
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 4308-015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------