Provider Demographics
NPI:1699709105
Name:DECKER, CORTNEY VAUGHN (DDS)
Entity type:Individual
Prefix:
First Name:CORTNEY
Middle Name:VAUGHN
Last Name:DECKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 OLD ENGLISH ROAD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720
Mailing Address - Country:US
Mailing Address - Phone:715-828-2675
Mailing Address - Fax:715-834-1988
Practice Address - Street 1:4605 ROYAL DRIVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701
Practice Address - Country:US
Practice Address - Phone:715-855-9220
Practice Address - Fax:715-855-9225
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI500-12021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391185385OtherTIN