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General NPI Number Information
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NPI Number | 1356476774
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Entity Type | Organization
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Legal Business Name | TIMBER DRIVE DENTAL INC.
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Dates
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Enumeration Date | 02/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 521 E TIMBER DR
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City | RHINELANDER
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State | WI
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Zip | 54501-2855
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Country | US
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Telephone | 715-365-1800
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Fax | 715-365-1806
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Provider Business Mailing Address
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Address Line | PO BOX 579
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City | RHINELANDER
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State | WI
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Zip | 54501-0579
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Country | US
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Telephone | 715-365-1800
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Fax | 715-365-1806
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Authorized Official
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Title or Position | DENTIST
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Name | DR. LEONARD FRALICK JR.
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Credential | D.D.S.
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Telephone | 715-365-1800
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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 | 4504
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License Number State | WI
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