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General NPI Number Information
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NPI Number | 1699985051
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Entity Type | Organization
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Legal Business Name | BEAVER DAM DENTAL LLC
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 01/31/2013
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Provider Practice Location Address
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Address Line | 302 N SPRING ST
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City | BEAVER DAM
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State | WI
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Zip | 53916-2044
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Country | US
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Telephone | 920-887-8421
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Fax | 920-887-8431
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Provider Business Mailing Address
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Address Line | PO BOX 436
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City | BEAVER DAM
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State | WI
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Zip | 53916-0436
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Country | US
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Telephone | 920-887-8421
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Fax | 920-887-8431
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Authorized Official
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Title or Position | PARTNER
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Name | MRS. GENEVIEVE E POPPE
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Credential |
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Telephone | 608-358-3370
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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 | 1384G
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6749-015
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3480
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License Number State | WI
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