Provider Demographics
NPI:1508932815
Name:NORTHPARK DENTAL - CHIPPEWA
Entity Type:Organization
Organization Name:NORTHPARK DENTAL - CHIPPEWA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTACT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GENIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-450-0157
Mailing Address - Street 1:235 W PRAIRIE VIEW RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-3639
Mailing Address - Country:US
Mailing Address - Phone:715-720-9125
Mailing Address - Fax:715-720-1475
Practice Address - Street 1:235 W PRAIRIE VIEW RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-3639
Practice Address - Country:US
Practice Address - Phone:715-720-9125
Practice Address - Fax:715-720-1475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty