Provider Demographics
NPI:1669684726
Name:ST CROIX PERIODONTICS
Entity Type:Organization
Organization Name:ST CROIX PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDSMS
Authorized Official - Phone:715-377-7860
Mailing Address - Street 1:1200 CRESTVIEW DRIVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-9391
Mailing Address - Country:US
Mailing Address - Phone:715-377-7860
Mailing Address - Fax:715-377-7862
Practice Address - Street 1:1200 CRESTVIEW DRIVE
Practice Address - Street 2:SUITE4
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9391
Practice Address - Country:US
Practice Address - Phone:715-377-7860
Practice Address - Fax:715-377-7862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty