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General NPI Number Information
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NPI Number | 1992486203
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Entity Type | Individual
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Provider Name | JUSTIN MICHAEL SERVAIS DMD
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Gender | Male
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Dates
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Enumeration Date | 07/28/2023
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | 2830 DARLING CT
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City | LA CROSSE
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State | WI
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Zip | 54601-2754
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Country | US
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Telephone | 608-783-7330
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Fax |
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Provider Business Mailing Address
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Address Line | 4702 CREEKWOOD LN APT 304
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City | MADISON
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State | WI
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Zip | 53704-2482
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Country | US
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Telephone | 608-790-0200
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 600131415
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License Number State | WI
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