Provider Demographics
NPI:1699985051
Name:BEAVER DAM DENTAL LLC
Entity type:Organization
Organization Name:BEAVER DAM DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:E
Authorized Official - Last Name:POPPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-358-3370
Mailing Address - Street 1:PO BOX 436
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-0436
Mailing Address - Country:US
Mailing Address - Phone:920-887-8421
Mailing Address - Fax:920-887-8431
Practice Address - Street 1:302 N SPRING ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2044
Practice Address - Country:US
Practice Address - Phone:920-887-8421
Practice Address - Fax:920-887-8431
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEPPING STONE DENTAL PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-23
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1384G1223G0001X
WI34801223G0001X
WI6749-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33555900Medicaid
WI1871881169Medicaid
WI33477900Medicaid