Provider Demographics
NPI:1730726555
Name:SUN PRAIRIE FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:SUN PRAIRIE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR OF ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-833-2213
Mailing Address - Street 1:8025 EXCELSIOR DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1900
Mailing Address - Country:US
Mailing Address - Phone:608-833-2213
Mailing Address - Fax:
Practice Address - Street 1:180 WILBURN RD
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1476
Practice Address - Country:US
Practice Address - Phone:608-833-2213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-01
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty