Provider Demographics
NPI:1457697229
Name:SAUK TRAIL DENTAL LLC
Entity Type:Organization
Organization Name:SAUK TRAIL DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:POPPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-358-3370
Mailing Address - Street 1:661 E GREEN BAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080-2013
Mailing Address - Country:US
Mailing Address - Phone:262-284-7111
Mailing Address - Fax:
Practice Address - Street 1:661 E GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080-2013
Practice Address - Country:US
Practice Address - Phone:262-284-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEPPING STONE DENTAL PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-21
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2485-15122300000X
WI2334-151223G0001X
WI6732-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty