Basic Information
| Provider Information | |||||||||
| NPI: | 1669549044 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAGLEVIEW DENTAL OFFICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 126 | ||||||||
| Address2: | 476 WATER ST. | ||||||||
| City: | PRAIRIE DU SAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535780126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086433855 | ||||||||
| FaxNumber: | 6086436295 | ||||||||
| Practice Location | |||||||||
| Address1: | 476 WATER ST | ||||||||
| Address2: | |||||||||
| City: | PRAIRIE DU SAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535781127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086433855 | ||||||||
| FaxNumber: | 6086436295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KNICKMEYER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 6086433855 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 5002061-015 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.