Provider Demographics
NPI:1588666747
Name:COMMUNITY DENTAL
Entity Type:Organization
Organization Name:COMMUNITY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BURLINGAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-284-9409
Mailing Address - Street 1:716 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-9108
Mailing Address - Country:US
Mailing Address - Phone:715-284-9409
Mailing Address - Fax:715-284-9167
Practice Address - Street 1:716 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-9108
Practice Address - Country:US
Practice Address - Phone:715-284-9409
Practice Address - Fax:715-284-9167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty