Provider Demographics
NPI:1457472797
Name:EBY FAMILY DENTAL
Entity Type:Organization
Organization Name:EBY FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:EBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-563-2928
Mailing Address - Street 1:715 SHERMAN AVE EAST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538
Mailing Address - Country:US
Mailing Address - Phone:920-563-2928
Mailing Address - Fax:920-563-6585
Practice Address - Street 1:715 SHERMAN AVE EAST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538
Practice Address - Country:US
Practice Address - Phone:920-563-2928
Practice Address - Fax:920-563-6585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
WI5909-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========OtherCORP. NO.