Provider Demographics
NPI:1063687150
Name:FAMILY DENTISTRY SC
Entity Type:Organization
Organization Name:FAMILY DENTISTRY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LINDQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-749-3724
Mailing Address - Street 1:PO BOX 118
Mailing Address - Street 2:205 S DIVISION ST
Mailing Address - City:ROBERTS
Mailing Address - State:WI
Mailing Address - Zip Code:54023
Mailing Address - Country:US
Mailing Address - Phone:715-749-3724
Mailing Address - Fax:715-246-6649
Practice Address - Street 1:205 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROBERTS
Practice Address - State:WI
Practice Address - Zip Code:54023
Practice Address - Country:US
Practice Address - Phone:715-749-3724
Practice Address - Fax:715-246-6649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38371000Medicaid