Basic Information
| Provider Information | |||||||||
| NPI: | 1992718019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHROEDER | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3600 TOWER AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548805337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153925411 | ||||||||
| FaxNumber: | 7153925086 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 TOWER AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548805337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153925411 | ||||||||
| FaxNumber: | 7153925086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 12/12/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 3346 | WI | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 505020500 | 05 | MN | MEDICAID | 33467600 | 05 | WI | MEDICAID | 3346 | 01 | WI | LICENSE | OTHER |