| NPI | 1164550208 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MICHAEL CHARLES EBBEN President 920-788-3542 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 2739) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 4142) |
| Enumeration Date | 2007-03-01 |
| Last Update Date | 2020-08-22 |