Provider Demographics
NPI:1205915287
Name:FAMILY DENTISTRY SC
Entity type:Organization
Organization Name:FAMILY DENTISTRY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MIKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-246-6493
Mailing Address - Street 1:135 W SECOND STREET
Mailing Address - Street 2:PO BOX 55
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017
Mailing Address - Country:US
Mailing Address - Phone:715-246-6603
Mailing Address - Fax:715-246-6649
Practice Address - Street 1:135 W SECOND STREET
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017
Practice Address - Country:US
Practice Address - Phone:715-246-6603
Practice Address - Fax:715-246-6649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38370900Medicaid