Provider Demographics
NPI:1053050336
Name:NORTH MAIN FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:NORTH MAIN FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-884-9341
Mailing Address - Street 1:2810 RIVERIDGE LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-9535
Mailing Address - Country:US
Mailing Address - Phone:920-530-0022
Mailing Address - Fax:
Practice Address - Street 1:717 MAIN AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-1426
Practice Address - Country:US
Practice Address - Phone:605-692-4715
Practice Address - Fax:605-692-2427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty