Provider Demographics
NPI:1164047130
Name:MEQUON DEER DENTAL, LLC
Entity Type:Organization
Organization Name:MEQUON DEER DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR 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 1:8025 EXCELSIOR DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7400 W BROWN DEER RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-2078
Practice Address - Country:US
Practice Address - Phone:414-354-1160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental