Provider Demographics
NPI:1861927535
Name:VISTA FAMILY DENTISTRY, LLC
Entity type:Organization
Organization Name:VISTA FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VASSILIS
Authorized Official - Middle Name:K
Authorized Official - Last Name:PANAGOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-717-9104
Mailing Address - Street 1:20855 WATERTOWN RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1860
Mailing Address - Country:US
Mailing Address - Phone:262-717-9104
Mailing Address - Fax:262-717-9105
Practice Address - Street 1:20855 WATERTOWN RD
Practice Address - Street 2:SUITE 120
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1860
Practice Address - Country:US
Practice Address - Phone:262-717-9104
Practice Address - Fax:262-717-9105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6265-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty