Provider Demographics
NPI:1689792079
Name:IOLA DENTAL CLINIC SC
Entity Type:Organization
Organization Name:IOLA DENTAL CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAYS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-445-2435
Mailing Address - Street 1:PO BOX 274
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54945
Mailing Address - Country:US
Mailing Address - Phone:715-445-2435
Mailing Address - Fax:715-445-2554
Practice Address - Street 1:100 PINE CREST LANE
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:WI
Practice Address - Zip Code:54945
Practice Address - Country:US
Practice Address - Phone:715-445-2435
Practice Address - Fax:715-445-2554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34410900Medicaid