Provider Demographics
NPI:1336645100
Name:CHIPPEWA VALLEY DENTAL, LLC
Entity Type:Organization
Organization Name:CHIPPEWA VALLEY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GENIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-833-8755
Mailing Address - Street 1:2914 LONDON RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2914 LONDON RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6831
Practice Address - Country:US
Practice Address - Phone:715-832-3832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty