Provider Demographics
NPI:1962910810
Name:RED CEDAR DENTISRY LLC
Entity type:Organization
Organization Name:RED CEDAR DENTISRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-309-2999
Mailing Address - Street 1:2409 HILS CT
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-1141
Mailing Address - Country:US
Mailing Address - Phone:715-309-2999
Mailing Address - Fax:715-309-2983
Practice Address - Street 1:2409 HILS CT
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-1141
Practice Address - Country:US
Practice Address - Phone:715-309-2999
Practice Address - Fax:715-309-2983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7263-15261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental