Provider Demographics
NPI: | 1790188852 |
---|---|
Name: | APPLE CREEK LTD |
Entity Type: | Organization |
Organization Name: | APPLE CREEK LTD |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | JAMES |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | TOMASSETTI |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 920-738-7600 |
Mailing Address - Street 1: | 2310 E EVERGREEN DR |
Mailing Address - Street 2: | SUITE B |
Mailing Address - City: | APPLETON |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 54913-7404 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 920-738-7600 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2310 E EVERGREEN DR |
Practice Address - Street 2: | SUITE B |
Practice Address - City: | APPLETON |
Practice Address - State: | WI |
Practice Address - Zip Code: | 54913-7404 |
Practice Address - Country: | US |
Practice Address - Phone: | 920-738-7600 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-10-03 |
Last Update Date: | 2014-10-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WI | 5699 | 1223X0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223X0400X | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | Group - Single Specialty |