Provider Demographics
NPI:1841696127
Name:EAU CLAIRE FAMILY DENTAL
Entity type:Organization
Organization Name:EAU CLAIRE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-832-8063
Mailing Address - Street 1:1018 REGIS CT
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4404
Mailing Address - Country:US
Mailing Address - Phone:715-832-8063
Mailing Address - Fax:715-835-1231
Practice Address - Street 1:1018 REGIS CT
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4404
Practice Address - Country:US
Practice Address - Phone:715-832-8063
Practice Address - Fax:715-835-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619063195OtherNPI
1245466317OtherNPI
WI1578657276OtherNPI