1417298696 NPI number — LITTLE SPROUTS DENTAL, 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 1417298696 NPI number — LITTLE SPROUTS DENTAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LITTLE SPROUTS DENTAL, 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:
LITTLE SPROUTS DENTAL
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:
1417298696
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W62N563 WASHINGTON AVE
Provider Second Line Business Mailing Address:
LOWER LEVEL
Provider Business Mailing Address City Name:
CEDARBURG
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53012-1986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-297-0079
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W62N563 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
CEDARBURG
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53012-1986
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-297-0079
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LANGEWISCH
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
262-297-0079

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  5824-15 , 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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