=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396514899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGH BRIDGE PERIODONTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2023
-----------------------------------------------------
Last Update Date | 12/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3203 STEIN BLVD STE B
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54701-6946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-835-1060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2921 LANDMARK PL STE 215
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53713-4248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-817-3252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL CONTROLLER
-----------------------------------------------------
Name | MR. ANDREW ZIEGLER
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 608-817-3252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------