Provider Demographics
NPI:1811498561
Name:ORTHODONTIC SPECIALISTS OF ONALASKA AND THE COULEE REGION
Entity type:Organization
Organization Name:ORTHODONTIC SPECIALISTS OF ONALASKA AND THE COULEE REGION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KUJAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:608-783-8333
Mailing Address - Street 1:2747 NATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8784
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2747 NATIONAL DR
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8784
Practice Address - Country:US
Practice Address - Phone:608-783-8333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty