Provider Demographics
NPI:1639279433
Name:DOWNTOWN DENTAL, S.C.
Entity Type:Organization
Organization Name:DOWNTOWN DENTAL, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:HAFDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-294-2334
Mailing Address - Street 1:114 CASCADE ST.
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-0387
Mailing Address - Country:US
Mailing Address - Phone:715-294-2334
Mailing Address - Fax:715-294-2220
Practice Address - Street 1:114 CASCADE ST.
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020-0387
Practice Address - Country:US
Practice Address - Phone:715-294-2334
Practice Address - Fax:715-294-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty