=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588972590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL IMPLANT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2010
-----------------------------------------------------
Last Update Date | 09/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1202 COUNTY ROAD PH SUITE 300
-----------------------------------------------------
City | ONALASKA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54650-8439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-783-7330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1202 COUNTY ROAD PH SUITE 300
-----------------------------------------------------
City | ONALASKA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54650-8439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTACT OFFICER
-----------------------------------------------------
Name | GENIE KUBLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-450-0157
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------