Provider Demographics
NPI:1730390840
Name:CESA #11 RURAL HEALTH DENTAL CLINIC
Entity type:Organization
Organization Name:CESA #11 RURAL HEALTH DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUGERUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-986-2020
Mailing Address - Street 1:225 OSTERMANN DR
Mailing Address - Street 2:
Mailing Address - City:TURTLE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54889-9191
Mailing Address - Country:US
Mailing Address - Phone:715-986-2020
Mailing Address - Fax:715-986-2041
Practice Address - Street 1:3375 KOTHLOW AVE.
Practice Address - Street 2:SUITE 40
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751
Practice Address - Country:US
Practice Address - Phone:715-235-1573
Practice Address - Fax:715-235-2081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38389000Medicaid