Provider Demographics
NPI:1316954928
Name:ORAL AND MAXILLOFACIAL SURGERY ASSO OF EAU CLAIRE SC
Entity type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY ASSO OF EAU CLAIRE SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TRANSCRIPTION AND CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:K
Authorized Official - Last Name:THOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-834-8414
Mailing Address - Street 1:1120 OAK RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701
Mailing Address - Country:US
Mailing Address - Phone:715-834-8414
Mailing Address - Fax:715-834-3557
Practice Address - Street 1:788 OAKLEAF WAY
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720
Practice Address - Country:US
Practice Address - Phone:715-834-8414
Practice Address - Fax:715-834-3557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4680-015204E00000X
WI5112-015204E00000X
WI5563-015204E00000X
1223E0200X, 1223S0112X
WI6222-151223E0200X
WI4412-0151223E0200X
WI4495-015204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI79441Medicare PIN