Provider Demographics
NPI:1417175951
Name:JOEL A. EGGERT D.D.S.,S.C.
Entity Type:Organization
Organization Name:JOEL A. EGGERT D.D.S.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EGGERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-743-4334
Mailing Address - Street 1:14 S 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-2246
Mailing Address - Country:US
Mailing Address - Phone:920-743-4334
Mailing Address - Fax:
Practice Address - Street 1:14 S 3RD AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2246
Practice Address - Country:US
Practice Address - Phone:920-743-4334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2080G122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33372100Medicaid