Provider Demographics
NPI:1093415283
Name:WINNECONNE FAMILY DENTISTRY ACQUISITION LLC
Entity Type:Organization
Organization Name:WINNECONNE FAMILY DENTISTRY ACQUISITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDEHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-229-7092
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:WINNECONNE
Mailing Address - State:WI
Mailing Address - Zip Code:54986-0520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:902 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNECONNE
Practice Address - State:WI
Practice Address - Zip Code:54986-9782
Practice Address - Country:US
Practice Address - Phone:920-705-1123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental