Provider Demographics
NPI:1992396360
Name:PORTWASHINGTONCTD1 LLC
Entity Type:Organization
Organization Name:PORTWASHINGTONCTD1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEILAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-343-0818
Mailing Address - Street 1:8025 EXCELSIOR DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1900
Mailing Address - Country:US
Mailing Address - Phone:608-343-0818
Mailing Address - Fax:
Practice Address - Street 1:222 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1903
Practice Address - Country:US
Practice Address - Phone:262-235-4525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty