1184793580 NPI number — GENERATIONS FAMILY DENTAL

Table of content: (NPI 1184793580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184793580 NPI number — GENERATIONS FAMILY DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENERATIONS FAMILY DENTAL
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:
1184793580
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2505 N MAYFAIR RD
Provider Second Line Business Mailing Address:
#103
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-258-2117
Provider Business Mailing Address Fax Number:
414-258-4177

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2505 N MAYFAIR RD
Provider Second Line Business Practice Location Address:
#103
Provider Business Practice Location Address City Name:
WAUWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-258-2117
Provider Business Practice Location Address Fax Number:
414-258-4177
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LACOURT
Authorized Official First Name:
FRED
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
414-258-2117

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3547WI , 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: 690859 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 98924 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".




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