Provider Demographics
NPI:1568566057
Name:DOUGLAS D PODOLL DDS DC
Entity Type:Organization
Organization Name:DOUGLAS D PODOLL DDS DC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:PODOLL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-268-8109
Mailing Address - Street 1:404 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001
Mailing Address - Country:US
Mailing Address - Phone:715-268-8109
Mailing Address - Fax:715-268-4620
Practice Address - Street 1:404 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001
Practice Address - Country:US
Practice Address - Phone:715-268-8109
Practice Address - Fax:715-268-4620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty