Provider Demographics
NPI:1255573184
Name:PLATTEVILLE DENTAL LLC
Entity type:Organization
Organization Name:PLATTEVILLE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACQUINOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-852-7298
Mailing Address - Street 1:1270 N WATER ST
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-1450
Mailing Address - Country:US
Mailing Address - Phone:608-348-2393
Mailing Address - Fax:608-348-4430
Practice Address - Street 1:1270 N WATER ST
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-1450
Practice Address - Country:US
Practice Address - Phone:608-348-2393
Practice Address - Fax:608-348-4430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6103261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental