Provider Demographics
NPI:1679809974
Name:EASTPARK DENTAL LLC
Entity Type:Organization
Organization Name:EASTPARK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-222-8232
Mailing Address - Street 1:5100 EASTPARK BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-2149
Mailing Address - Country:US
Mailing Address - Phone:608-222-8232
Mailing Address - Fax:608-222-8340
Practice Address - Street 1:5100 EASTPARK BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-2149
Practice Address - Country:US
Practice Address - Phone:608-222-8232
Practice Address - Fax:608-222-8340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty