Provider Demographics
NPI:1750836623
Name:FLAVIN, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:FLAVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E BRIDGE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3574
Mailing Address - Country:US
Mailing Address - Phone:715-843-9800
Mailing Address - Fax:715-843-9819
Practice Address - Street 1:200 E BRIDGE ST STE 100
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-3574
Practice Address - Country:US
Practice Address - Phone:715-843-9800
Practice Address - Fax:715-843-9819
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001413122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist