Provider Demographics
NPI:1073136420
Name:GENERATIONS FAMILY DENTAL CARE-TOSA, LLC
Entity Type:Organization
Organization Name:GENERATIONS FAMILY DENTAL CARE-TOSA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:BABCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-258-2117
Mailing Address - Street 1:2505 N MAYFAIR RD STE 103
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1404
Mailing Address - Country:US
Mailing Address - Phone:414-258-2117
Mailing Address - Fax:
Practice Address - Street 1:2505 N MAYFAIR RD STE 103
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1404
Practice Address - Country:US
Practice Address - Phone:414-258-2117
Practice Address - Fax:414-258-4117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty