Provider Demographics
NPI:1437329901
Name:DR. BRIAN J. UNDERWOOD, D.D.S., S.C.
Entity Type:Organization
Organization Name:DR. BRIAN J. UNDERWOOD, D.D.S., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-695-2918
Mailing Address - Street 1:105 5TH AVE N
Mailing Address - Street 2:PO BOX 400
Mailing Address - City:STRUM
Mailing Address - State:WI
Mailing Address - Zip Code:54770-9252
Mailing Address - Country:US
Mailing Address - Phone:715-695-2918
Mailing Address - Fax:715-695-3852
Practice Address - Street 1:105 5TH AVE N
Practice Address - Street 2:
Practice Address - City:STRUM
Practice Address - State:WI
Practice Address - Zip Code:54770-9252
Practice Address - Country:US
Practice Address - Phone:715-695-2918
Practice Address - Fax:715-695-3852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3750261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33693400Medicaid
391675083011OtherBLUE CROSS BLUE SHIELD
391675083001OtherDELTA DENTAL