Provider Demographics
NPI:1083929814
Name:KING FAMILY DENTISTRY
Entity Type:Organization
Organization Name:KING FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LAUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-282-5560
Mailing Address - Street 1:6520 W LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4500
Mailing Address - Country:US
Mailing Address - Phone:414-282-5560
Mailing Address - Fax:414-282-6790
Practice Address - Street 1:6520 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4500
Practice Address - Country:US
Practice Address - Phone:414-282-5560
Practice Address - Fax:414-282-6790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5258-151223G0001X
WI5001352-121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5001352-12OtherDENTIST
WI5258-15OtherDENTIST