Provider Demographics
NPI:1174620330
Name:CAMERON DENTAL CLINIC LTD
Entity type:Organization
Organization Name:CAMERON DENTAL CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER OF CAMERON DENTAL CLINIC LT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-458-4470
Mailing Address - Street 1:PO BOX 360
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WI
Mailing Address - Zip Code:54822-0360
Mailing Address - Country:US
Mailing Address - Phone:715-458-4470
Mailing Address - Fax:
Practice Address - Street 1:902 MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:WI
Practice Address - Zip Code:54822-0360
Practice Address - Country:US
Practice Address - Phone:715-458-4470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2677-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33423600Medicaid