Provider Demographics
NPI:1194188706
Name:FAMILIA DENTAL GREEN BAY EAST LLC
Entity Type:Organization
Organization Name:FAMILIA DENTAL GREEN BAY EAST LLC
Other - Org Name:FAMILIA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING & PAYER RELATIONS MAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:847-453-7396
Mailing Address - Street 1:2050 EAST ALGONQUIN ROAD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4166
Mailing Address - Country:US
Mailing Address - Phone:847-453-7396
Mailing Address - Fax:847-453-7396
Practice Address - Street 1:1931 MAIN ST.
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3920
Practice Address - Country:US
Practice Address - Phone:920-499-2770
Practice Address - Fax:920-634-2733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty