Provider Demographics
NPI:1295743193
Name:ASHLAND DENTAL CLINIC INC
Entity type:Organization
Organization Name:ASHLAND DENTAL CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:HAMBUCH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-682-2733
Mailing Address - Street 1:300 9TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806
Mailing Address - Country:US
Mailing Address - Phone:715-682-2733
Mailing Address - Fax:715-682-0226
Practice Address - Street 1:300 9TH AVE W
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806
Practice Address - Country:US
Practice Address - Phone:715-682-2733
Practice Address - Fax:715-682-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1779G122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33366500Medicaid