1174524425 NPI number — COMPLETE FAMILY DENTISTRY ON BROADWAY

Table of content: (NPI 1174524425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174524425 NPI number — COMPLETE FAMILY DENTISTRY ON BROADWAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPLETE FAMILY DENTISTRY ON BROADWAY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMPLETE FAMILY DENTISTRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174524425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
419 E BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUKESHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53186-5082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-549-6850
Provider Business Mailing Address Fax Number:
262-549-2157

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
419 E BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKESHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53186-5082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-549-6850
Provider Business Practice Location Address Fax Number:
262-549-2157
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JAHIMIAK
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
262-549-6850

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3689 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 33495600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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