Provider Demographics
NPI:1649607730
Name:DIRECT DENTURE SERVICE
Entity type:Organization
Organization Name:DIRECT DENTURE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-518-2859
Mailing Address - Street 1:3000 RILEY RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-6726
Mailing Address - Country:US
Mailing Address - Phone:608-518-2859
Mailing Address - Fax:608-269-6315
Practice Address - Street 1:3000 RILEY RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-6726
Practice Address - Country:US
Practice Address - Phone:608-518-2859
Practice Address - Fax:608-269-6315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5752261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental