Provider Demographics
NPI:1144241340
Name:WOODLAND DENTAL GRP., SC
Entity Type:Organization
Organization Name:WOODLAND DENTAL GRP., SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLS
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-662-3066
Mailing Address - Street 1:W232S7590 WOODLAND LN
Mailing Address - Street 2:
Mailing Address - City:BIG BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53103-9651
Mailing Address - Country:US
Mailing Address - Phone:262-662-3066
Mailing Address - Fax:262-662-2070
Practice Address - Street 1:W232S7590 WOODLAND LN
Practice Address - Street 2:
Practice Address - City:BIG BEND
Practice Address - State:WI
Practice Address - Zip Code:53103-9651
Practice Address - Country:US
Practice Address - Phone:262-662-3066
Practice Address - Fax:262-662-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI79300OtherWPS#
WI79300OtherWPS#