Provider Demographics
NPI:1265605265
Name:WESTERN WISCONSIN ORAL HEALTH INITIATIVE
Entity type:Organization
Organization Name:WESTERN WISCONSIN ORAL HEALTH INITIATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM HEAD
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JERUE
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:608-785-9843
Mailing Address - Street 1:304 6TH ST N
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 BADGER ST
Practice Address - Street 2:HEALTH SCIENCE CENTER
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-1502
Practice Address - Country:US
Practice Address - Phone:608-789-6101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental