Provider Demographics
NPI:1659961670
Name:HIXON HILLS DENTAL, LLC
Entity Type:Organization
Organization Name:HIXON HILLS DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOREY
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDE WALLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-782-9667
Mailing Address - Street 1:1800 STATE ROAD 16
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3011
Mailing Address - Country:US
Mailing Address - Phone:608-782-9667
Mailing Address - Fax:
Practice Address - Street 1:1800 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3011
Practice Address - Country:US
Practice Address - Phone:608-782-9667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-23
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental