Provider Demographics
NPI:1225553753
Name:MAYFAIF FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MAYFAIF FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ARIF-HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-259-0665
Mailing Address - Street 1:11637 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11637 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2129
Practice Address - Country:US
Practice Address - Phone:414-259-0665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-05
Last Update Date:2017-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6448-15261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1982867024Medicaid