Provider Demographics
NPI:1457716763
Name:BLACK CREEK DENTAL LLC
Entity Type:Organization
Organization Name:BLACK CREEK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:LORNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-984-3315
Mailing Address - Street 1:PO BOX 255
Mailing Address - Street 2:
Mailing Address - City:BLACK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54106-0255
Mailing Address - Country:US
Mailing Address - Phone:920-984-3315
Mailing Address - Fax:920-984-3317
Practice Address - Street 1:207 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACK CREEK
Practice Address - State:WI
Practice Address - Zip Code:54106-9742
Practice Address - Country:US
Practice Address - Phone:920-984-3315
Practice Address - Fax:920-984-3317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4932-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty