Provider Demographics
NPI:1437571320
Name:WATERLOO FAMILY DENTAL,
Entity Type:Organization
Organization Name:WATERLOO FAMILY DENTAL,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FORSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-623-5559
Mailing Address - Street 1:245 N. MONROE STREET
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:WI
Mailing Address - Zip Code:53594
Mailing Address - Country:US
Mailing Address - Phone:920-478-2850
Mailing Address - Fax:
Practice Address - Street 1:245 N. MONROE STREET
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:WI
Practice Address - Zip Code:53594
Practice Address - Country:US
Practice Address - Phone:920-478-2850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty