# IDENTAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1508316753
- **Authorized official:** MS. MARIAN 'TRACIE' CLUBB (ASSISTANT MANAGER)
- **Authorized official phone:** (262) 223-0280

## Contact information

- **Practice address:** 1320 S GREEN BAY RD, MOUNT PLEASANT, WI 53406-4402
- **Practice address phone:** (262) 223-0280
- **Practice address fax:** (262) 223-0281
- **Mailing address:** 1320 S GREEN BAY RD, MOUNT PLEASANT, WI 53406-4402
- **Mailing address phone:** (262) 223-0280
- **Mailing address fax:** (262) 223-0281

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 124Q00000X | Dental Hygienist | 5279 | WI | Yes |

## Other

- **Enumeration date:** 10/12/2016
- **Last updated:** 11/16/2016