Provider Demographics
NPI:1659863199
Name:NEIGHBORHOOD SMILES OF WEST SALEM, LLC
Entity Type:Organization
Organization Name:NEIGHBORHOOD SMILES OF WEST SALEM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-842-3933
Mailing Address - Street 1:301 N 17TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4225
Mailing Address - Country:US
Mailing Address - Phone:608-519-4385
Mailing Address - Fax:
Practice Address - Street 1:1403 WATERLOO AVE
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-9270
Practice Address - Country:US
Practice Address - Phone:608-519-4385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental