1093595548 NPI number — HOMESTEAD DENTAL LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093595548 NPI number — HOMESTEAD DENTAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOMESTEAD DENTAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093595548
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N1881 SAVANNAH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54942-8597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-858-6907
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1580 W. AMERICAN DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEENAH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54956-5494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-858-6907
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2023

Additional Information

Authorized Official

Authorized Official Last Name:
WOLFINGER
Authorized Official First Name:
MEGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
920-858-6907

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1730613555 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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