Provider Demographics
NPI:1215177555
Name:RIVER PLACE DENTAL, INC
Entity type:Organization
Organization Name:RIVER PLACE DENTAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLLYN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-268-2103
Mailing Address - Street 1:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-0106
Mailing Address - Country:US
Mailing Address - Phone:715-268-2103
Mailing Address - Fax:715-268-7729
Practice Address - Street 1:1030 RIVER PLACE DRIVE
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001
Practice Address - Country:US
Practice Address - Phone:715-268-2103
Practice Address - Fax:715-268-7729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-26
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIV10843Medicare UPIN