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General NPI Number Information
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NPI Number | 1457697229
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Entity Type | Organization
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Legal Business Name | SAUK TRAIL DENTAL LLC
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Dates
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Enumeration Date | 12/21/2012
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Last Update Date | 06/04/2014
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Provider Practice Location Address
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Address Line | 661 E GREEN BAY AVE
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City | SAUKVILLE
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State | WI
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Zip | 53080-2013
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Country | US
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Telephone | 262-284-7111
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Fax |
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Provider Business Mailing Address
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Address Line | 661 E GREEN BAY AVE
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City | SAUKVILLE
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State | WI
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Zip | 53080-2013
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Country | US
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Telephone | 262-284-7111
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | GENEVIEVE POPPE
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Credential |
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Telephone | 608-358-3370
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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 | 2485-15
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2334-15
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License Number State | WI
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