Provider Demographics
NPI:1629224852
Name:DENTAL ASSOCIATES OF LAKE MILLS, INC.
Entity Type:Organization
Organization Name:DENTAL ASSOCIATES OF LAKE MILLS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCHLEICHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-648-2331
Mailing Address - Street 1:311 E TYRANENA PARK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-9681
Mailing Address - Country:US
Mailing Address - Phone:920-648-2331
Mailing Address - Fax:920-648-3437
Practice Address - Street 1:311 E TYRANENA PARK RD
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-9681
Practice Address - Country:US
Practice Address - Phone:920-648-2331
Practice Address - Fax:920-648-3437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3647122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33489300Medicaid
WI33794300Medicaid