1710498514 NPI number — GERALD L IGNACE INDIAN DENTAL CENTER, LLC

Table of content: MS. VANESSA G FICHTNER MS, CCC/SLP (NPI 1346557204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710498514 NPI number — GERALD L IGNACE INDIAN DENTAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERALD L IGNACE INDIAN DENTAL CENTER, 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:
1710498514
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 W HISTORIC MITCHELL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53204-3533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-389-9526
Provider Business Mailing Address Fax Number:
414-649-2711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 W HISTORIC MITCHELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53204-3533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-389-9526
Provider Business Practice Location Address Fax Number:
414-649-2711
Provider Enumeration Date:
10/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
TURNER
Authorized Official First Name:
DANDRE
Authorized Official Middle Name:
LASHUN
Authorized Official Title or Position:
BILLING SPECIALIST
Authorized Official Telephone Number:
414-316-5052

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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