Provider Demographics
NPI:1861256620
Name:FALL CREEK FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:FALL CREEK FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NPI AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GENIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-450-0157
Mailing Address - Street 1:122 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:FALL CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54742-9701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 S STATE ST
Practice Address - Street 2:
Practice Address - City:FALL CREEK
Practice Address - State:WI
Practice Address - Zip Code:54742-9701
Practice Address - Country:US
Practice Address - Phone:715-877-2113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty