Provider Demographics
NPI:1154834018
Name:DRIFTLESS DENTAL CARE, LLC
Entity Type:Organization
Organization Name:DRIFTLESS DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-833-2213
Mailing Address - Street 1:3143 STATE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-6964
Mailing Address - Country:US
Mailing Address - Phone:608-787-1700
Mailing Address - Fax:
Practice Address - Street 1:3143 STATE RD STE 200
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6964
Practice Address - Country:US
Practice Address - Phone:608-787-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty