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General NPI Number Information
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NPI Number | 1932467222
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Entity Type | Organization
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Legal Business Name | AFFORDABLE DENTURES - EAU CLAIRE, S.C.
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Dates
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Enumeration Date | 04/25/2012
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Last Update Date | 04/25/2012
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Provider Practice Location Address
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Address Line | 4850 KEYSTONE XING
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City | EAU CLAIRE
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State | WI
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Zip | 54701-5076
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Country | US
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Telephone | 715-855-1020
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Fax |
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Provider Business Mailing Address
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Address Line | 4850 KEYSTONE XING
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City | EAU CLAIRE
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State | WI
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Zip | 54701-5076
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRACTICE OWNER
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Name | DR. PHILLIP DOUGLAS
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Credential | DDS
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Telephone | 715-855-1020
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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 | 6330-015
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License Number State | WI
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