Provider Demographics
NPI:1306112685
Name:QUIRT FAMILY DENTISTRY, SC
Entity type:Organization
Organization Name:QUIRT FAMILY DENTISTRY, SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:3417 SCHOFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-2572
Mailing Address - Country:US
Mailing Address - Phone:715-355-5570
Mailing Address - Fax:
Practice Address - Street 1:3417 SCHOFIELD AVE
Practice Address - Street 2:
Practice Address - City:SCHOFIELD
Practice Address - State:WI
Practice Address - Zip Code:54476-2572
Practice Address - Country:US
Practice Address - Phone:715-355-5570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUIRT FAMILY DENTISTRY, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty