Provider Demographics
NPI:1417004177
Name:ANTIGO DENTAL CLINIC L.L.C.
Entity Type:Organization
Organization Name:ANTIGO DENTAL CLINIC L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGHAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-627-4391
Mailing Address - Street 1:707 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409
Mailing Address - Country:US
Mailing Address - Phone:715-627-4391
Mailing Address - Fax:715-627-4392
Practice Address - Street 1:707 6TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409
Practice Address - Country:US
Practice Address - Phone:715-627-4391
Practice Address - Fax:715-627-4392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001261-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty