Provider Demographics
NPI:1154477818
Name:THE GENTLE DENTAL EMPORIUM LLC
Entity Type:Organization
Organization Name:THE GENTLE DENTAL EMPORIUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-338-8704
Mailing Address - Street 1:533 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095
Mailing Address - Country:US
Mailing Address - Phone:262-338-8704
Mailing Address - Fax:262-338-9140
Practice Address - Street 1:533 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095
Practice Address - Country:US
Practice Address - Phone:262-338-8704
Practice Address - Fax:262-338-9140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2517K122300000X
WIWI5624122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty