Provider Demographics
NPI:1295955342
Name:FALL CREEK DENTAL
Entity type:Organization
Organization Name:FALL CREEK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PILGRIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-877-2113
Mailing Address - Street 1:122 STATE ST
Mailing Address - Street 2:BOX 66
Mailing Address - City:FALL CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54742
Mailing Address - Country:US
Mailing Address - Phone:715-877-2113
Mailing Address - Fax:715-877-3495
Practice Address - Street 1:122 STATE ST
Practice Address - Street 2:
Practice Address - City:FALL CREEK
Practice Address - State:WI
Practice Address - Zip Code:54742
Practice Address - Country:US
Practice Address - Phone:715-877-2113
Practice Address - Fax:715-877-3495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty