Provider Demographics
NPI:1235404732
Name:QUIRT FAMILY DENTISTRY, SC
Entity Type:Organization
Organization Name:QUIRT FAMILY DENTISTRY, SC
Other - Org Name:QUIRT FAMILY DENTISTRY - WAUSAU
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:200 E BRIDGE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3574
Mailing Address - Country:US
Mailing Address - Phone:715-843-9800
Mailing Address - Fax:
Practice Address - Street 1:200 E BRIDGE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-3574
Practice Address - Country:US
Practice Address - Phone:715-843-9800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUIRT FAMILY DENTISTRY, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty