Provider Demographics
NPI:1417721531
Name:RIVERSIDE FAMILY DENTAL
Entity Type:Organization
Organization Name:RIVERSIDE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-712-6500
Mailing Address - Street 1:N84W15865 APPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3087
Mailing Address - Country:US
Mailing Address - Phone:262-251-6980
Mailing Address - Fax:262-735-4823
Practice Address - Street 1:N84W15865 APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3087
Practice Address - Country:US
Practice Address - Phone:262-251-6980
Practice Address - Fax:262-735-4823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental