| Black Creek Dental Llc | |
|
207 S Main St Black Creek WI 54106-9742 | |
| (920) 984-3315 | |
| (920) 984-3317 |
| Full Name | Black Creek Dental Llc |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 207 S Main St, Black Creek, Wisconsin |
| Authorized Official Name and Position | Thomas E Lornson (OWNER) |
| Authorized Official Contact | 9209843315 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Black Creek Dental Llc Po Box 255 Black Creek WI 54106-0255 Ph: (920) 984-3315 | Black Creek Dental Llc 207 S Main St Black Creek WI 54106-9742 Ph: (920) 984-3315 |
| NPI Number | 1457716763 |
|---|---|
| Provider Enumeration Date | 12/31/2015 |
| Last Update Date | 12/31/2015 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1457716763 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 4932-15 (Wisconsin) | Primary |