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General NPI Number Information
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NPI Number | 1700110574
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Entity Type | Organization
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Legal Business Name | DEER CREEK DENTAL CLINIC, LTD
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Dates
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Enumeration Date | 09/28/2009
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Last Update Date | 03/13/2014
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Provider Practice Location Address
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Address Line | 820 N SUPERIOR AVE
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City | TOMAH
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State | WI
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Zip | 54660-1120
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Country | US
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Telephone | 608-372-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 820 N SUPERIOR AVE
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City | TOMAH
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State | WI
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Zip | 54660-1120
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Country | US
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Telephone | 608-372-5000
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Fax |
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | MRS. KATHERINE E KONZE
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Credential | PHR
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Telephone | 608-372-5000
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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 | 3857
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License Number State | WI
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