Basic Information
| Provider Information | |||||||||
| NPI: | 1629220983 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AWDM, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3189 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132203189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154546000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4113 RIB MOUNTAIN DRIVE | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153596060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2008 | ||||||||
| LastUpdateDate: | 10/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | FONTANA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3154546000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.