Provider Demographics
NPI:1538232202
Name:UNIVERISTY DENTAL LLC
Entity type:Organization
Organization Name:UNIVERISTY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:TACHE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,FAGD
Authorized Official - Phone:920-437-7444
Mailing Address - Street 1:1833 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-3637
Mailing Address - Country:US
Mailing Address - Phone:920-437-7444
Mailing Address - Fax:920-437-7862
Practice Address - Street 1:1833 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3637
Practice Address - Country:US
Practice Address - Phone:920-437-7444
Practice Address - Fax:920-437-7862
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
MA5089-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty