Provider Demographics
NPI:1053432955
Name:FIRST CITY DENTAL OF ABBOTSFORD, SC
Entity type:Organization
Organization Name:FIRST CITY DENTAL OF ABBOTSFORD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:D
Authorized Official - Last Name:RENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-223-4844
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:ABBOTSFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54405-0147
Mailing Address - Country:US
Mailing Address - Phone:715-223-4844
Mailing Address - Fax:715-223-6957
Practice Address - Street 1:202 BIRCH ST
Practice Address - Street 2:
Practice Address - City:ABBOTSFORD
Practice Address - State:WI
Practice Address - Zip Code:54405-9439
Practice Address - Country:US
Practice Address - Phone:715-223-4844
Practice Address - Fax:715-223-6957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI4941122300000X
WIWI4940122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33742800Medicaid
WI33742700Medicaid