Provider Demographics
NPI:1700110574
Name:DEER CREEK DENTAL CLINIC, LTD
Entity Type:Organization
Organization Name:DEER CREEK DENTAL CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:E
Authorized Official - Last Name:KONZE
Authorized Official - Suffix:
Authorized Official - Credentials:PHR
Authorized Official - Phone:608-372-5000
Mailing Address - Street 1:820 N SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-1120
Mailing Address - Country:US
Mailing Address - Phone:608-372-5000
Mailing Address - Fax:
Practice Address - Street 1:820 N SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-1120
Practice Address - Country:US
Practice Address - Phone:608-372-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3857261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental