Provider Demographics
NPI:1962874511
Name:SMILES FOR EAU CLAIRE COUNTY LLC
Entity type:Organization
Organization Name:SMILES FOR EAU CLAIRE COUNTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:715-836-0127
Mailing Address - Street 1:1811 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7900
Mailing Address - Country:US
Mailing Address - Phone:715-836-0127
Mailing Address - Fax:
Practice Address - Street 1:1811 MEADOW LN
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-7900
Practice Address - Country:US
Practice Address - Phone:715-836-0127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4176-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty