Provider Demographics
NPI:1558837658
Name:PEERENBOOM DENTAL LLC
Entity Type:Organization
Organization Name:PEERENBOOM DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR OF ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-833-2213
Mailing Address - Street 1:8025 EXCELSIOR DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1900
Mailing Address - Country:US
Mailing Address - Phone:608-833-2213
Mailing Address - Fax:
Practice Address - Street 1:1 CORPORATE DR STE 100
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-1724
Practice Address - Country:US
Practice Address - Phone:608-833-2213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty