Provider Demographics
NPI:1073026936
Name:MARATHON FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:MARATHON FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-833-2213
Mailing Address - Street 1:981 BLUE STONE LN
Mailing Address - Street 2:
Mailing Address - City:MARATHON
Mailing Address - State:WI
Mailing Address - Zip Code:54448-6800
Mailing Address - Country:US
Mailing Address - Phone:715-443-2200
Mailing Address - Fax:
Practice Address - Street 1:981 BLUE STONE LN
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:WI
Practice Address - Zip Code:54448-6800
Practice Address - Country:US
Practice Address - Phone:715-443-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty