Provider Demographics
NPI:1518972389
Name:JUST KIDS DENTAL SC
Entity Type:Organization
Organization Name:JUST KIDS DENTAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:K
Authorized Official - Last Name:MARCHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-452-7336
Mailing Address - Street 1:1313 N TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3041
Mailing Address - Country:US
Mailing Address - Phone:920-452-7336
Mailing Address - Fax:920-453-9770
Practice Address - Street 1:1313 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3041
Practice Address - Country:US
Practice Address - Phone:920-452-7336
Practice Address - Fax:920-453-9770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52360151223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33762400Medicaid