Organization
BLACK CREEK DENTAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. THOMAS E LORNSON DDS (OWNER)
(920) 984-3315
Entity
Organization
Contact information
Practice address
207 S MAIN ST, BLACK CREEK, WI 54106-9742
(920) 984-3315
(920) 984-3317
Mailing address
PO BOX 255, BLACK CREEK, WI 54106-0255
(920) 984-3315
(920) 984-3317
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
4932-15
WI
Other
Enumeration date
12/31/2015
Last updated
12/31/2015
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