Organization
MOUNTAIN BAY DENTAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LANAE W JOHNSON (MANAGER)
(715) 496-1128
Entity
Organization
Contact information
Practice address
3510 MARIANNA DR, CHAMPAIGN, IL 61822-9502
(715) 496-1128
Mailing address
5702 MEMORIAL CT, WESTON, WI 54476-6502
(715) 496-1128
(715) 972-8123
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
1001483
WI
Other
Enumeration date
04/08/2017
Last updated
04/08/2017
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