Provider Demographics
NPI:1558357020
Name:SUEPPEL, JAMES R (DDS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:SUEPPEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 39
Mailing Address - Street 2:238 FRONT STREET SCENIC BLUFFS HEALTH CENTER
Mailing Address - City:CASHTON
Mailing Address - State:WI
Mailing Address - Zip Code:54619
Mailing Address - Country:US
Mailing Address - Phone:608-654-5100
Mailing Address - Fax:608-654-5120
Practice Address - Street 1:238 FRONT STREET
Practice Address - Street 2:SCENIC BLUFFS HEALTH CENTER
Practice Address - City:CASHTON
Practice Address - State:WI
Practice Address - Zip Code:54619
Practice Address - Country:US
Practice Address - Phone:608-654-5100
Practice Address - Fax:608-654-5120
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA075431223G0001X
WI6171-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003913Medicaid
IA07543OtherIA STATE LICENSE #
IA7543OtherDELTA DENTAL (IA)
IA0080200Medicaid
IA1417959OtherCONTROLLED SUBSTANCE#
IA421060724OtherBILLING TAX ID# FOR CHC
990360OtherUNITED CONCORDIA
IAIA0156OtherJOHN DEERE EDI#
WI1558357020Medicaid
IA7543OtherBC/BS OF IA-BLUE DENTAL
IA7543OtherBC/BS OF IA-BLUE DENTAL