Provider Demographics
NPI:1386636959
Name:DENTAL PARK SC
Entity Type:Organization
Organization Name:DENTAL PARK SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BOETTCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-682-0321
Mailing Address - Street 1:1503 RANDOLPH CT
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-8345
Mailing Address - Country:US
Mailing Address - Phone:920-682-0321
Mailing Address - Fax:920-682-3128
Practice Address - Street 1:1503 RANDOLPH CT
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-8345
Practice Address - Country:US
Practice Address - Phone:920-682-0321
Practice Address - Fax:920-682-3128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental