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General NPI Number Information
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NPI Number | 1578832853
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Entity Type | Organization
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Legal Business Name | EAU CLAIRE PERIODONTICS, L.L.C.
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Dates
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Enumeration Date | 12/15/2011
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Last Update Date | 12/15/2011
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Provider Practice Location Address
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Address Line | 2125 HEIGHTS DR STE 2C
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City | EAU CLAIRE
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State | WI
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Zip | 54701-6146
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Country | US
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Telephone | 715-832-5396
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Fax | 715-832-3009
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Provider Business Mailing Address
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Address Line | 2125 HEIGHTS DR STE 2C
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City | EAU CLAIRE
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State | WI
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Zip | 54701-6146
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Country | US
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Telephone | 715-832-5396
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Fax | 715-832-3009
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Authorized Official
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Title or Position | CHIEF MANAGER/PERIODONTIST
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Name | DR. JASON D. JOHNSON
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Credential | D.D.S., M.S.
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Telephone | 715-832-5396
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 6810-015
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License Number State | WI
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