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General NPI Number Information
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NPI Number | 1467169409
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Entity Type | Organization
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Legal Business Name | LTC DENTAL III LLC
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Dates
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Enumeration Date | 10/31/2022
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Last Update Date | 04/06/2023
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Provider Practice Location Address
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Address Line | 1314 S 1ST ST # 276
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City | MILWAUKEE
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State | WI
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Zip | 53204-2405
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Country | US
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Telephone | 888-970-3400
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Fax | 888-456-3812
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Provider Business Mailing Address
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Address Line | 2314 S ROUTE 59 STE 384
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City | PLAINFIELD
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State | IL
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Zip | 60586-7756
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Country | US
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Telephone | 888-970-3400
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Fax | 888-456-3812
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Authorized Official
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Title or Position | OWNER
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Name | TARA ROBINSON
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Credential |
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Telephone | 407-375-3003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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