Provider Demographics
NPI:1114230968
Name:TWIN PORTS DENTAL
Entity Type:Organization
Organization Name:TWIN PORTS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTACT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GENIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-450-0157
Mailing Address - Street 1:1507 TOWER AVE
Mailing Address - Street 2:ROOM 427
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-2532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1507 TOWER AVE
Practice Address - Street 2:ROOM 427
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2532
Practice Address - Country:US
Practice Address - Phone:715-394-5792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty