Provider Demographics
NPI:1669549044
Name:EAGLEVIEW DENTAL OFFICE
Entity type:Organization
Organization Name:EAGLEVIEW DENTAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:KNICKMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-643-3855
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:476 WATER ST.
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-0126
Mailing Address - Country:US
Mailing Address - Phone:608-643-3855
Mailing Address - Fax:608-643-6295
Practice Address - Street 1:476 WATER ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1127
Practice Address - Country:US
Practice Address - Phone:608-643-3855
Practice Address - Fax:608-643-6295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5002061-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty