Provider Demographics
NPI:1063563674
Name:DOUGLAS D PODOLL DDS SC
Entity type:Organization
Organization Name:DOUGLAS D PODOLL DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:PODOLL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-684-5858
Mailing Address - Street 1:1460 10TH AVE
Mailing Address - Street 2:PO BOX 516
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002
Mailing Address - Country:US
Mailing Address - Phone:715-684-5858
Mailing Address - Fax:715-684-5968
Practice Address - Street 1:1460 10TH AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002
Practice Address - Country:US
Practice Address - Phone:715-684-5858
Practice Address - Fax:715-684-5968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty