Provider Demographics
NPI:1356414114
Name:TIMBERCREST DENTAL CENTER, S.C.
Entity type:Organization
Organization Name:TIMBERCREST DENTAL CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BERTON
Authorized Official - Last Name:LUTHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-734-9148
Mailing Address - Street 1:821 E 1ST AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1501
Mailing Address - Country:US
Mailing Address - Phone:920-734-9148
Mailing Address - Fax:920-734-8710
Practice Address - Street 1:821 E 1ST AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1501
Practice Address - Country:US
Practice Address - Phone:920-734-9148
Practice Address - Fax:920-734-8710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5588-015261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental