Provider Demographics
NPI:1043483357
Name:RANDY R CIEPLUCH
Entity Type:Organization
Organization Name:RANDY R CIEPLUCH
Other - Org Name:FAMILY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CIEPLUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-342-0378
Mailing Address - Street 1:3500 W LISBON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-1953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:414-342-1008
Practice Address - Street 1:3500 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1953
Practice Address - Country:US
Practice Address - Phone:414-342-0378
Practice Address - Fax:414-342-1008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2260-015261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental