MEDICARE: GILLETT DENTAL CARE, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5002024-015	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5002024-015	OTHER	WI	STATE DENTAL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356554851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GILLETT DENTAL CARE, S.C.

Provider Business Mailing Address
First Line	:	137 E MAIN ST
Second Line	:	P.O. BOX 266
City	:	GILLETT
State	:	WI
Zip	:	54124-9386
Country	:	US
Telephone Number	:	920-855-6091
Fax Number	:

Provider Business Practice Location Address
First Line	:	137 E MAIN ST
Second Line	:
City	:	GILLETT
State	:	WI
Zip	:	54124-9386
Country	:	US
Telephone Number	:	920-855-6091
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EVELYN KATRINA HAUSER-FREDERICK
Credential	:
Telephone Number	:	920-855-2155

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	06/17/2014

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Directions to “GILLETT DENTAL CARE, S.C. ” Practice Location

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