Provider Demographics
NPI:1376747493
Name:POTH FAMILY DENTAL, S.C.
Entity Type:Organization
Organization Name:POTH FAMILY DENTAL, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EVERETT
Authorized Official - Last Name:POTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-692-2461
Mailing Address - Street 1:100 MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53021-9455
Mailing Address - Country:US
Mailing Address - Phone:262-692-2461
Mailing Address - Fax:262-692-9889
Practice Address - Street 1:100 MARTIN DR
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:WI
Practice Address - Zip Code:53021-9455
Practice Address - Country:US
Practice Address - Phone:262-692-2461
Practice Address - Fax:262-692-9889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4245-015261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental