Provider Demographics
NPI:1093113789
Name:PRESCOTT FAMILY DENTAL
Entity Type:Organization
Organization Name:PRESCOTT FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CASSIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-262-3382
Mailing Address - Street 1:1015 CAMPBELL ST N
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:WI
Mailing Address - Zip Code:54021-1157
Mailing Address - Country:US
Mailing Address - Phone:715-262-3382
Mailing Address - Fax:715-262-3063
Practice Address - Street 1:1015 CAMPBELL ST N
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:WI
Practice Address - Zip Code:54021-1157
Practice Address - Country:US
Practice Address - Phone:715-262-3382
Practice Address - Fax:715-262-3063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-11
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35231223G0001X
WI69321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100024073Medicaid
WI33478900Medicaid