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General NPI Number Information
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NPI Number | 1538232202
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Entity Type | Organization
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Legal Business Name | UNIVERISTY DENTAL LLC
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1833 UNIVERSITY AVE
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City | GREEN BAY
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State | WI
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Zip | 54302-3637
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Country | US
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Telephone | 920-437-7444
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Fax | 920-437-7862
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Provider Business Mailing Address
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Address Line | 1833 UNIVERSITY AVE
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City | GREEN BAY
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State | WI
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Zip | 54302-3637
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Country | US
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Telephone | 920-437-7444
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Fax | 920-437-7862
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Authorized Official
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Title or Position | OWNER
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Name | DR. DANIEL E TACHE
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Credential | D.M.D.,F.A.G.D.
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Telephone | 920-437-7444
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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 | 5089-015
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License Number State | MA
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