Provider Demographics
NPI:1073598165
Name:ZANDER DENTAL SC
Entity Type:Organization
Organization Name:ZANDER DENTAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ZANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-526-3314
Mailing Address - Street 1:152 WOODLAWN DR
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2200
Mailing Address - Country:US
Mailing Address - Phone:715-526-3314
Mailing Address - Fax:715-524-9893
Practice Address - Street 1:152 WOODLAWN DR
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2200
Practice Address - Country:US
Practice Address - Phone:715-526-3314
Practice Address - Fax:715-524-9893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2262015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33386000Medicaid