MEDICARE: SAUK TRAIL DENTAL LLC

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	2485-15	WI
2	1223G0001X	General Practice Dentistry	2334-15	WI

General Provider Information

NPI Number	:	1457697229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAUK TRAIL DENTAL LLC

Provider Business Mailing Address
First Line	:	661 E GREEN BAY AVE
Second Line	:
City	:	SAUKVILLE
State	:	WI
Zip	:	53080-2013
Country	:	US
Telephone Number	:	262-284-7111
Fax Number	:

Provider Business Practice Location Address
First Line	:	661 E GREEN BAY AVE
Second Line	:
City	:	SAUKVILLE
State	:	WI
Zip	:	53080-2013
Country	:	US
Telephone Number	:	262-284-7111
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	GENEVIEVE POPPE
Credential	:
Telephone Number	:	608-358-3370

Provider Enumeration Date	:	12/21/2012
Last Update Date	:	06/04/2014

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Directions to “SAUK TRAIL DENTAL LLC ” Practice Location

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