Provider Demographics
NPI:1225568983
Name:DE PERE SMILES ACQUISITION COMPANY S.C.
Entity Type:Organization
Organization Name:DE PERE SMILES ACQUISITION COMPANY S.C.
Other - Org Name:DE PERE SMILES S.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:920-336-6594
Mailing Address - Street 1:277 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-1548
Mailing Address - Country:US
Mailing Address - Phone:920-336-6594
Mailing Address - Fax:920-336-7132
Practice Address - Street 1:277 N 9TH ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-1548
Practice Address - Country:US
Practice Address - Phone:920-336-6594
Practice Address - Fax:920-336-7132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001273-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty