Provider Demographics
NPI:1508316753
Name:IDENTAL
Entity Type:Organization
Organization Name:IDENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:'TRACIE'
Authorized Official - Last Name:CLUBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-223-0280
Mailing Address - Street 1:1320 S GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4402
Mailing Address - Country:US
Mailing Address - Phone:262-223-0280
Mailing Address - Fax:262-223-0281
Practice Address - Street 1:1320 S GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4402
Practice Address - Country:US
Practice Address - Phone:262-223-0280
Practice Address - Fax:262-223-0281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5279124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty