Provider Demographics
NPI:1285141481
Name:CHIPPEWA VALLEY ENDODONTICS LLC
Entity type:Organization
Organization Name:CHIPPEWA VALLEY ENDODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BODA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:715-552-8165
Mailing Address - Street 1:3004 GOLF RD STE 102
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-8794
Mailing Address - Country:US
Mailing Address - Phone:715-552-8165
Mailing Address - Fax:
Practice Address - Street 1:3004 GOLF RD STE 102
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-8794
Practice Address - Country:US
Practice Address - Phone:715-552-8165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6901-151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty