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General NPI Number Information
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NPI Number | 1609987288
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Entity Type | Organization
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Legal Business Name | ACACIA LANE DENTAL, S.C.
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 664 ACACIA LN
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City | RHINELANDER
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State | WI
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Zip | 54501-2873
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Country | US
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Telephone | 715-365-8664
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Fax | 715-365-8668
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Provider Business Mailing Address
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Address Line | PO BOX 1165 664 ACACIA LANE
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City | RHINELANDER
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State | WI
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Zip | 54501-1165
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Country | US
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Telephone | 715-365-8664
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Fax | 715-365-8668
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GREGORY DANA EDWARDS
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Credential | D.D.S.
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Telephone | 715-365-8664
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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 | WI
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