Provider Demographics
NPI:1093595548
Name:HOMESTEAD DENTAL LLC
Entity Type:Organization
Organization Name:HOMESTEAD DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-858-6907
Mailing Address - Street 1:N1881 SAVANNAH DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-8597
Mailing Address - Country:US
Mailing Address - Phone:920-858-6907
Mailing Address - Fax:
Practice Address - Street 1:1580 W. AMERICAN DRIVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-5494
Practice Address - Country:US
Practice Address - Phone:920-858-6907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1730613555Medicaid