1053430991 NPI number — ASSOCIATED FAMILY DENTISTRY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053430991 NPI number — ASSOCIATED FAMILY DENTISTRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSOCIATED FAMILY DENTISTRY LLC
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:
Provider Other Organization Name Type Code:
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:
1053430991
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:
845 S MAIN ST
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54935-6174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-922-7012
Provider Business Mailing Address Fax Number:
920-921-7101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
845 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
FOND DU LAC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54935-6174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-922-7012
Provider Business Practice Location Address Fax Number:
920-921-7101
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SARAUER
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
TOMCHEK
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
920-922-7012

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  4618-015 , 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)





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