Provider Demographics
NPI:1336237551
Name:TRI-COUNTY COMMUNITY DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:TRI-COUNTY COMMUNITY DENTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DREXLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-882-9989
Mailing Address - Street 1:9 TRI PARK WAY
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1661
Mailing Address - Country:US
Mailing Address - Phone:920-882-9989
Mailing Address - Fax:920-882-9961
Practice Address - Street 1:9 TRI PARK WAY
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1661
Practice Address - Country:US
Practice Address - Phone:920-882-9989
Practice Address - Fax:920-882-9961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38392800Medicaid