Provider Demographics
NPI:1356489603
Name:EAST TOWNE DENTAL ASSOCIATED BELGIUM FAMILY DENTAL SC
Entity Type:Organization
Organization Name:EAST TOWNE DENTAL ASSOCIATED BELGIUM FAMILY DENTAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VALI
Authorized Official - Middle Name:
Authorized Official - Last Name:KIAIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-241-8880
Mailing Address - Street 1:11501 N PROT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092
Mailing Address - Country:US
Mailing Address - Phone:262-241-8880
Mailing Address - Fax:262-241-5250
Practice Address - Street 1:11501 N PROT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092
Practice Address - Country:US
Practice Address - Phone:262-241-8880
Practice Address - Fax:262-241-5250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5301122300000X
WI5304122300000X
WI5993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty