Provider Demographics
NPI:1164996997
Name:ST. CROIX DENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:ST. CROIX DENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-483-0429
Mailing Address - Street 1:235 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-4117
Mailing Address - Country:US
Mailing Address - Phone:715-483-3261
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:26425 LAKELAND AVE S
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-8343
Practice Address - Country:US
Practice Address - Phone:715-866-4420
Practice Address - Fax:715-866-4368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-15
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty