Provider Demographics
NPI:1013038207
Name:NORTHERN DOOR DENTAL SC
Entity Type:Organization
Organization Name:NORTHERN DOOR DENTAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRACTICE PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MALCOLM
Authorized Official - Last Name:MAYHEW
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-854-5200
Mailing Address - Street 1:10589 S HIGHLAND RD STE 4
Mailing Address - Street 2:
Mailing Address - City:SISTER BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54234
Mailing Address - Country:US
Mailing Address - Phone:920-854-5200
Mailing Address - Fax:920-854-7601
Practice Address - Street 1:10589 S HIGHLAND RD STE 4
Practice Address - Street 2:
Practice Address - City:SISTER BAY
Practice Address - State:WI
Practice Address - Zip Code:54234
Practice Address - Country:US
Practice Address - Phone:920-854-5200
Practice Address - Fax:920-854-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50020200151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33368800Medicaid