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General NPI Number Information
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NPI Number | 1649607730
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Entity Type | Organization
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Legal Business Name | DIRECT DENTURE SERVICE
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Dates
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Enumeration Date | 10/03/2013
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Last Update Date | 10/03/2013
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Provider Practice Location Address
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Address Line | 3000 RILEY RD
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City | SPARTA
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State | WI
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Zip | 54656-6726
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Country | US
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Telephone | 608-518-2859
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Fax | 608-269-6315
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Provider Business Mailing Address
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Address Line | 3000 RILEY RD
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City | SPARTA
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State | WI
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Zip | 54656-6726
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Country | US
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Telephone | 608-518-2859
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Fax | 608-269-6315
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Authorized Official
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Title or Position | DENTIST
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Name | DR. STEPHEN JOHNSTON
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Credential |
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Telephone | 608-518-2859
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 5752
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License Number State | MN
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