Provider Demographics
NPI:1083283626
Name:FAMILIA DENTAL MKE MIDTOWN LLC
Entity Type:Organization
Organization Name:FAMILIA DENTAL MKE MIDTOWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & PAYOR RELATIONS MAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:847-453-7393
Mailing Address - Street 1:2050 E ALGONQUIN ROAD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4166
Mailing Address - Country:US
Mailing Address - Phone:847-453-7396
Mailing Address - Fax:847-453-9390
Practice Address - Street 1:5341 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1365
Practice Address - Country:US
Practice Address - Phone:414-871-0827
Practice Address - Fax:414-871-0859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental