Provider Demographics
NPI:1508598202
Name:EAST PARK DENTAL, LLC
Entity Type:Organization
Organization Name:EAST PARK DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-222-8232
Mailing Address - Street 1:5100 EASTPARK BLVD.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718
Mailing Address - Country:US
Mailing Address - Phone:608-222-8232
Mailing Address - Fax:608-244-7442
Practice Address - Street 1:5100 EASTPARK BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718
Practice Address - Country:US
Practice Address - Phone:608-222-8232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty