MEDICARE: ROSHOLT AREA DENTAL CLINIC, 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

General Provider Information

NPI Number	:	1518470475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSHOLT AREA DENTAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	247 DEPOT ST
Second Line	:
City	:	ROSHOLT
State	:	WI
Zip	:	54473-9710
Country	:	US
Telephone Number	:	715-677-3202
Fax Number	:

Provider Business Practice Location Address
First Line	:	247 DEPOT ST
Second Line	:
City	:	ROSHOLT
State	:	WI
Zip	:	54473-9710
Country	:	US
Telephone Number	:	715-677-3202
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF ACCOUNTING
Name	:	OLGA GRENOVA
Credential	:
Telephone Number	:	608-833-2213

Provider Enumeration Date	:	11/14/2017
Last Update Date	:	11/14/2017

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