Provider Demographics
NPI:1891172425
Name:SUNRIDGE DENTAL LLC
Entity Type:Organization
Organization Name:SUNRIDGE DENTAL LLC
Other - Org Name:JILL M CARTER, DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-468-8085
Mailing Address - Street 1:2926 FINGER RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7548
Mailing Address - Country:US
Mailing Address - Phone:920-468-8085
Mailing Address - Fax:
Practice Address - Street 1:2926 FINGER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-7548
Practice Address - Country:US
Practice Address - Phone:920-468-8085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6367122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty