# BOYS AND GIRLS CLUB OF PORTAGE COUNTY

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

## Provider details

- **NPI number:** 1962916650
- **Authorized official:** MELISSA GUTIERREZ RDH (SMILE CLUB COORDINATOR)
- **Authorized official phone:** (715) 204-1180

## Contact information

- **Practice address:** 941 MICHIGAN AVE, STEVENS POINT, WI 54481
- **Practice address phone:** (715) 204-1180
- **Mailing address:** PO BOX 171, STEVENS POINT, WI 54481

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 124Q00000X | Dental Hygienist | 10047-16 | WI | Yes |

## Other

- **Enumeration date:** 11/17/2017
- **Last updated:** 11/17/2017