Provider Demographics
NPI:1649273285
Name:LOBERG, ERIC TODD (DDS)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:TODD
Last Name:LOBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 DEXTER ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2523
Mailing Address - Country:US
Mailing Address - Phone:920-531-1479
Mailing Address - Fax:
Practice Address - Street 1:15397 STATE HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WI
Practice Address - Zip Code:54138-9702
Practice Address - Country:US
Practice Address - Phone:715-276-6321
Practice Address - Fax:715-276-1428
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5234-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI337-63800Medicaid
WI337-63800Medicaid