Provider Demographics
NPI:1407387483
Name:GENERATIONS FAMILY DENTAL CARE-RANDOM LAKE, LLC
Entity Type:Organization
Organization Name:GENERATIONS FAMILY DENTAL CARE-RANDOM LAKE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:LACOURT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FAGD
Authorized Official - Phone:414-258-2117
Mailing Address - Street 1:2505 N MAYFAIR RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1404
Mailing Address - Country:US
Mailing Address - Phone:414-258-2117
Mailing Address - Fax:
Practice Address - Street 1:37 HICKORY DR
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075-1675
Practice Address - Country:US
Practice Address - Phone:920-994-4367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty