Provider Demographics
NPI:1396105474
Name:MDC BELLEVUE, L.L.C.
Entity type:Organization
Organization Name:MDC BELLEVUE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:MAUTHE
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-921-1244
Mailing Address - Street 1:7 SHEBOYGAN ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4281
Mailing Address - Country:US
Mailing Address - Phone:920-922-8171
Mailing Address - Fax:
Practice Address - Street 1:2040 CENTRAL CT
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6276
Practice Address - Country:US
Practice Address - Phone:920-468-0504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty