=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356414114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIMBERCREST DENTAL CENTER, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 E 1ST AVE SUITE 3
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54911-1501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-734-9148
-----------------------------------------------------
Fax | 920-734-8710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 821 E 1ST AVE SUITE 3
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54911-1501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-734-9148
-----------------------------------------------------
Fax | 920-734-8710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN BERTON LUTHER
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 920-734-9148
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 5588-015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------