Provider Demographics
NPI:1073604013
Name:KAUKAUNA FAMILY DENTISTRY, S.C.
Entity Type:Organization
Organization Name:KAUKAUNA FAMILY DENTISTRY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:FARROW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-766-9542
Mailing Address - Street 1:233 DODGE ST
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-2500
Mailing Address - Country:US
Mailing Address - Phone:920-766-9542
Mailing Address - Fax:920-759-4439
Practice Address - Street 1:233 DODGE ST
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-2500
Practice Address - Country:US
Practice Address - Phone:920-766-9542
Practice Address - Fax:920-759-4439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001987-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38377600Medicaid