Provider Demographics
NPI:1497294722
Name:MDC WEST BEND, LLC
Entity Type:Organization
Organization Name:MDC WEST BEND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLKA
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:920-579-3188
Mailing Address - Street 1:7 SHEBOYGAN ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4281
Mailing Address - Country:US
Mailing Address - Phone:920-579-3188
Mailing Address - Fax:
Practice Address - Street 1:1625 W PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-7846
Practice Address - Country:US
Practice Address - Phone:262-338-2992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN DENTAL CARE HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5479015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty