Organization
EVERGREEN DENTAL PARTNERS LLC
Active
Other names
Evergreen Dental
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JACOB M HUSTAD DMD (DENTIST)
(608) 345-1410
Entity
Organization
Contact information
Practice address
2310 E EVERGREEN DR STE A, APPLETON, WI 54913-7405
(608) 345-1410
Mailing address
2310 E EVERGREEN DR STE A, APPLETON, WI 54913-7405
(608) 345-1410
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Enumeration date
09/11/2024
Last updated
09/11/2024
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