Provider Demographics
NPI:1861694929
Name:LODI VALLEY GENTLE DENTAL LLP
Entity type:Organization
Organization Name:LODI VALLEY GENTLE DENTAL LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNERCHIP CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-592-4398
Mailing Address - Street 1:216 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:WI
Mailing Address - Zip Code:53555-1121
Mailing Address - Country:US
Mailing Address - Phone:608-592-4398
Mailing Address - Fax:608-592-5245
Practice Address - Street 1:216 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:WI
Practice Address - Zip Code:53555-1121
Practice Address - Country:US
Practice Address - Phone:608-592-4398
Practice Address - Fax:608-592-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001592261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33561900Medicaid