Provider Demographics
NPI:1215194832
Name:NORTHWEST WISCONSIN UPPER PENINSULA DENTAL PC
Entity Type:Organization
Organization Name:NORTHWEST WISCONSIN UPPER PENINSULA DENTAL PC
Other - Org Name:N E W UP DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:HALF OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-863-2206
Mailing Address - Street 1:4103 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MENOMINEE
Mailing Address - State:MI
Mailing Address - Zip Code:49858-1309
Mailing Address - Country:US
Mailing Address - Phone:906-863-2206
Mailing Address - Fax:906-863-6389
Practice Address - Street 1:4103 10TH ST
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-1309
Practice Address - Country:US
Practice Address - Phone:906-863-2206
Practice Address - Fax:906-863-6389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901010258122300000X
MI2901017418122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty