Provider Demographics
NPI:1285760751
Name:OAK PARK DENTAL CLINIC
Entity type:Organization
Organization Name:OAK PARK DENTAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:E
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-349-2297
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-0269
Mailing Address - Country:US
Mailing Address - Phone:715-349-2297
Mailing Address - Fax:715-349-2298
Practice Address - Street 1:24164 HIGHWAY 35-70
Practice Address - Street 2:
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872
Practice Address - Country:US
Practice Address - Phone:715-349-2297
Practice Address - Fax:715-349-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental