Provider Demographics
NPI:1356476774
Name:TIMBER DRIVE DENTAL INC.
Entity Type:Organization
Organization Name:TIMBER DRIVE DENTAL INC.
Other - Org Name:PACO FRALICK D.D.S.
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FRALICK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-365-1800
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-0579
Mailing Address - Country:US
Mailing Address - Phone:715-365-1800
Mailing Address - Fax:715-365-1806
Practice Address - Street 1:521 E TIMBER DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-2855
Practice Address - Country:US
Practice Address - Phone:715-365-1800
Practice Address - Fax:715-365-1806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4504122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty