Organization
IDENTAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MARIAN 'TRACIE' CLUBB (ASSISTANT MANAGER)
(262) 223-0280
Entity
Organization
Contact information
Practice address
1320 S GREEN BAY RD, MOUNT PLEASANT, WI 53406-4402
(262) 223-0280
(262) 223-0281
Mailing address
1320 S GREEN BAY RD, MOUNT PLEASANT, WI 53406-4402
(262) 223-0280
(262) 223-0281
Taxonomy
Speciality
Code
Description
License number
State
124Q00000X
Dental Hygienist
Primary
5279
WI
Other
Enumeration date
10/12/2016
Last updated
11/16/2016
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