Provider Demographics
NPI:1689018848
Name:HANNEMAN DUSTRUDE DENTAL LLC
Entity Type:Organization
Organization Name:HANNEMAN DUSTRUDE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:HANNEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-233-6001
Mailing Address - Street 1:1218 WITZEL AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-5659
Mailing Address - Country:US
Mailing Address - Phone:920-233-6001
Mailing Address - Fax:920-233-9769
Practice Address - Street 1:1218 WITZEL AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-5659
Practice Address - Country:US
Practice Address - Phone:920-233-6001
Practice Address - Fax:920-233-9769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty