Provider Demographics
NPI:1790045904
Name:MENNONITE DENTAL CLINIC
Entity Type:Organization
Organization Name:MENNONITE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IRVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-669-3790
Mailing Address - Street 1:W8180 COUNTY ROAD X
Mailing Address - Street 2:
Mailing Address - City:THORP
Mailing Address - State:WI
Mailing Address - Zip Code:54771-7512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W8180 COUNTY ROAD X
Practice Address - Street 2:
Practice Address - City:THORP
Practice Address - State:WI
Practice Address - Zip Code:54771-7512
Practice Address - Country:US
Practice Address - Phone:715-669-3790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental