Provider Demographics
NPI:1164234290
Name:NESIC DENTL LOUNGE
Entity type:Organization
Organization Name:NESIC DENTL LOUNGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:NESIC
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-830-5729
Mailing Address - Street 1:570 SOUTHWIND DR UNIT 207
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-4713
Mailing Address - Country:US
Mailing Address - Phone:815-830-5729
Mailing Address - Fax:
Practice Address - Street 1:N71 W13040 W APPLETON AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051
Practice Address - Country:US
Practice Address - Phone:815-830-5729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental