Provider Demographics
NPI:1922130160
Name:CHARLES C. LOBERG D.D.S.,S.C.
Entity Type:Organization
Organization Name:CHARLES C. LOBERG D.D.S.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:LOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-982-5181
Mailing Address - Street 1:201 WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-1171
Mailing Address - Country:US
Mailing Address - Phone:920-982-5181
Mailing Address - Fax:920-982-1098
Practice Address - Street 1:201 WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-1171
Practice Address - Country:US
Practice Address - Phone:920-982-5181
Practice Address - Fax:920-982-1098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000793-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty