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General NPI Number Information
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NPI Number | 1699985754
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Entity Type | Organization
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Legal Business Name | CENTER FOR DENTISTRY AND ORTHODONTICS
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5625 WOODLAND ST
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City | STEVENS POINT
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State | WI
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Zip | 54481-8637
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Country | US
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Telephone | 715-341-8335
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Fax | 715-343-0977
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Provider Business Mailing Address
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Address Line | 292 MAPLE BLUFF RD
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City | STEVENS POINT
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State | WI
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Zip | 54481-9267
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Country | US
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Telephone | 715-345-2168
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Fax | 715-343-0977
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Authorized Official
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Title or Position | DENTISTRY
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Name | DR. GERALD S. WALCZAK
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Credential | D.D.S.
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Telephone | 715-341-8335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 3383
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License Number State | WI
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