Provider Demographics
NPI:1437312568
Name:WESTON FAMILY DENTAL SC
Entity Type:Organization
Organization Name:WESTON FAMILY DENTAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:BRETL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-432-0583
Mailing Address - Street 1:3109 SHOREY AVE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-5648
Mailing Address - Country:US
Mailing Address - Phone:715-241-6800
Mailing Address - Fax:
Practice Address - Street 1:8055 MEADOW ROCK DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5241
Practice Address - Country:US
Practice Address - Phone:715-241-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5378-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty