Provider Demographics
NPI:1902108814
Name:PURDY FAMILY DENTISTRY
Entity Type:Organization
Organization Name:PURDY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PURDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-381-9785
Mailing Address - Street 1:1730 8TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002
Mailing Address - Country:US
Mailing Address - Phone:715-688-3110
Mailing Address - Fax:
Practice Address - Street 1:1730 8TH AVENUE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002
Practice Address - Country:US
Practice Address - Phone:715-688-3110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PURDY FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5625122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty