# NORTHWEST WISCONSIN UPPER PENINSULA DENTAL PC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** N E W UP Dental
- **Organization subpart:** No

## Provider details

- **NPI number:** 1215194832
- **Authorized official:** DONALD THOMAS PARK DDS (HALF OWNER)
- **Authorized official phone:** (906) 863-2206

## Contact information

- **Practice address:** 4103 10TH ST, MENOMINEE, MI 49858-1309
- **Practice address phone:** (906) 863-2206
- **Practice address fax:** (906) 863-6389
- **Mailing address:** 4103 10TH ST, MENOMINEE, MI 49858-1309
- **Mailing address phone:** (906) 863-2206
- **Mailing address fax:** (906) 863-6389

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 2901010258 | MI | Yes |
| 122300000X | Dentist | 2901017418 | MI | — |

## Other

- **Enumeration date:** 05/21/2008
- **Last updated:** 05/21/2008