Provider Demographics
NPI:1679662324
Name:BETZ, JOHN H (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:BETZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 10TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4768
Mailing Address - Country:US
Mailing Address - Phone:608-782-4054
Mailing Address - Fax:608-782-2198
Practice Address - Street 1:615 10TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4768
Practice Address - Country:US
Practice Address - Phone:608-782-4054
Practice Address - Fax:608-782-2198
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50008731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
820798OtherUNITED CONCORDIA
IA0945873Medicaid
WI33563700Medicaid