Provider Demographics
NPI:1801305271
Name:WILLOW COVE DENTAL, LLC
Entity type:Organization
Organization Name:WILLOW COVE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WYN
Authorized Official - Middle Name:
Authorized Official - Last Name:STECKBAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:920-235-3251
Mailing Address - Street 1:2300 WITZEL AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-1700
Mailing Address - Country:US
Mailing Address - Phone:920-235-3251
Mailing Address - Fax:
Practice Address - Street 1:1195 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2045
Practice Address - Country:US
Practice Address - Phone:920-235-3251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5396-15261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental