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General NPI Number Information
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NPI Number | 1780288977
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Entity Type | Organization
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Legal Business Name | MT CALVARY DENTAL LLC
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Dates
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Enumeration Date | 11/28/2020
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Last Update Date | 11/28/2020
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Provider Practice Location Address
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Address Line | 100 EVERGREEN RD
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City | MOUNT CALVARY
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State | WI
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Zip | 53057-9726
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Country | US
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Telephone | 920-753-2771
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Fax |
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Provider Business Mailing Address
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Address Line | 3500 WOODVIEW LN
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City | SAUKVILLE
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State | WI
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Zip | 53080-1400
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Country | US
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Telephone | 920-645-1219
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. CAITLIN BLOOMER
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Credential | DDS
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Telephone | 920-645-1219
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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 |
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License Number State |
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