Provider Demographics
NPI:1114317815
Name:JACKSON FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:JACKSON FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CHARMOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-677-3003
Mailing Address - Street 1:N168W20060 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037-9382
Mailing Address - Country:US
Mailing Address - Phone:262-677-3003
Mailing Address - Fax:262-677-1641
Practice Address - Street 1:N168W20060 MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WI
Practice Address - Zip Code:53037-9382
Practice Address - Country:US
Practice Address - Phone:262-677-3003
Practice Address - Fax:262-677-1641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3671-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty