Provider Demographics
NPI:1053950956
Name:ACACIA LANE DENTAL - RHINELANDER
Entity type:Organization
Organization Name:ACACIA LANE DENTAL - RHINELANDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GENIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-833-8755
Mailing Address - Street 1:935 NICOLET AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:664 ACACIA LN
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-2873
Practice Address - Country:US
Practice Address - Phone:715-365-8664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty