Provider Demographics
NPI:1245433580
Name:BLUE DIAMOND FAMILY DENTAL SC
Entity type:Organization
Organization Name:BLUE DIAMOND FAMILY DENTAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-568-2363
Mailing Address - Street 1:1502 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724-1686
Mailing Address - Country:US
Mailing Address - Phone:715-568-2363
Mailing Address - Fax:715-568-2373
Practice Address - Street 1:1502 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724-1686
Practice Address - Country:US
Practice Address - Phone:715-568-2363
Practice Address - Fax:715-568-2373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38390300Medicaid