=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750605580
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOWLING DENTAL CLINIC OF OMRO, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2010
-----------------------------------------------------
Last Update Date | 03/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1771 E MAIN ST
-----------------------------------------------------
City | OMRO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54963-1594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-685-2121
-----------------------------------------------------
Fax | 920-685-0467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1771 E MAIN ST PO BOX 503
-----------------------------------------------------
City | OMRO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54963-1594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-685-2121
-----------------------------------------------------
Fax | 920-685-0467
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. THOMAS M DOWLING
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 920-685-2121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3181
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------