Provider Demographics
NPI:1457507329
Name:MORK DENTAL, SC
Entity Type:Organization
Organization Name:MORK DENTAL, SC
Other - Org Name:FOUNTAIN CITY FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MORK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-687-3571
Mailing Address - Street 1:34 N MAIN ST
Mailing Address - Street 2:PO BOX 367
Mailing Address - City:FOUNTAIN CITY
Mailing Address - State:WI
Mailing Address - Zip Code:54629-8705
Mailing Address - Country:US
Mailing Address - Phone:608-687-3571
Mailing Address - Fax:
Practice Address - Street 1:34 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN CITY
Practice Address - State:WI
Practice Address - Zip Code:54629-8705
Practice Address - Country:US
Practice Address - Phone:608-687-3571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5882015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33814900Medicaid