Provider Demographics
NPI:1588972590
Name:DENTAL IMPLANT CENTER
Entity type:Organization
Organization Name:DENTAL IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTACT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GENIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-450-0157
Mailing Address - Street 1:1202 COUNTY ROAD PH
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1202 COUNTY ROAD PH
Practice Address - Street 2:SUITE 300
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8439
Practice Address - Country:US
Practice Address - Phone:608-783-7330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty