Provider Demographics
NPI:1447279625
Name:CEDAR CREEK DENTAL WI, S.C.
Entity type:Organization
Organization Name:CEDAR CREEK DENTAL WI, S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:BARR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-359-0550
Mailing Address - Street 1:1851 COUNTY ROAD XX
Mailing Address - Street 2:
Mailing Address - City:MOSINEE
Mailing Address - State:WI
Mailing Address - Zip Code:54455-7933
Mailing Address - Country:US
Mailing Address - Phone:715-359-0550
Mailing Address - Fax:
Practice Address - Street 1:1851 COUNTY ROAD XX
Practice Address - Street 2:
Practice Address - City:MOSINEE
Practice Address - State:WI
Practice Address - Zip Code:54455-7933
Practice Address - Country:US
Practice Address - Phone:715-359-0550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00032720151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty