Provider Demographics
NPI:1376607408
Name:EAST TROY FAMILY DENTAL CENTER SC
Entity Type:Organization
Organization Name:EAST TROY FAMILY DENTAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:NYFFELER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-642-5695
Mailing Address - Street 1:PO BOX 642
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120
Mailing Address - Country:US
Mailing Address - Phone:262-642-5695
Mailing Address - Fax:262-642-5395
Practice Address - Street 1:2481 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120
Practice Address - Country:US
Practice Address - Phone:262-642-5695
Practice Address - Fax:262-642-5395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38368500Medicaid
WI=========018OtherBLUE CROSS