Provider Demographics
NPI:1558476184
Name:TOMAH FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:TOMAH FAMILY DENTISTRY LLC
Other - Org Name:CHITWOOD NICOL & MATTHEWS LLP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHITWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-372-3298
Mailing Address - Street 1:PO BOX 606
Mailing Address - Street 2:214 LARKIN ST
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-0606
Mailing Address - Country:US
Mailing Address - Phone:608-372-3298
Mailing Address - Fax:608-372-3128
Practice Address - Street 1:214 LARKIN ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660
Practice Address - Country:US
Practice Address - Phone:608-372-3298
Practice Address - Fax:608-372-3128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty