Provider Demographics
NPI:1366848509
Name:SEUBERT FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:SEUBERT FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR./DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:SEUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-742-2331
Mailing Address - Street 1:260 W. COOK ST.
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-2106
Mailing Address - Country:US
Mailing Address - Phone:608-742-2331
Mailing Address - Fax:608-742-4308
Practice Address - Street 1:260 W. COOK ST.
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-2106
Practice Address - Country:US
Practice Address - Phone:608-742-2331
Practice Address - Fax:608-742-4308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty