Provider Demographics
NPI:1053972661
Name:OCONOMOWOC DENTAL ANESTHESIA CENTER
Entity type:Organization
Organization Name:OCONOMOWOC DENTAL ANESTHESIA CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOPKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-514-4992
Mailing Address - Street 1:888 THACKERAY TRL STE 214
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4342
Mailing Address - Country:US
Mailing Address - Phone:262-567-9116
Mailing Address - Fax:
Practice Address - Street 1:888 THACKERAY TRL STE 214
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4342
Practice Address - Country:US
Practice Address - Phone:262-567-9116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery