Provider Demographics
NPI:1699985754
Name:CENTER FOR DENTISTRY AND ORTHODONTICS
Entity type:Organization
Organization Name:CENTER FOR DENTISTRY AND ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-341-8335
Mailing Address - Street 1:292 MAPLE BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-9267
Mailing Address - Country:US
Mailing Address - Phone:715-345-2168
Mailing Address - Fax:715-343-0977
Practice Address - Street 1:5625 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-8637
Practice Address - Country:US
Practice Address - Phone:715-341-8335
Practice Address - Fax:715-343-0977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty