Provider Demographics
NPI:1962531178
Name:ORAL SURGERY CLINIC OF LA CROSSE LTD.
Entity type:Organization
Organization Name:ORAL SURGERY CLINIC OF LA CROSSE LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LUDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-782-8193
Mailing Address - Street 1:2819 NATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-6703
Mailing Address - Country:US
Mailing Address - Phone:608-782-8193
Mailing Address - Fax:608-782-4517
Practice Address - Street 1:2819 NATIONAL DR
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-6703
Practice Address - Country:US
Practice Address - Phone:608-782-8193
Practice Address - Fax:608-782-4517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33757600Medicaid
WI835478OtherUNITED CONCORDIA
WI33757600Medicaid