Provider Demographics
NPI:1225307267
Name:DE PERE FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:DE PERE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER / MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYRIL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:VAN SISTINE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-336-2500
Mailing Address - Street 1:1001 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2609
Mailing Address - Country:US
Mailing Address - Phone:920-336-2500
Mailing Address - Fax:920-336-4684
Practice Address - Street 1:1001 N BROADWAY
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2609
Practice Address - Country:US
Practice Address - Phone:920-336-2500
Practice Address - Fax:920-336-4684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50014991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty