Provider Demographics
NPI:1558710269
Name:DENTAL ASSOSIATES
Entity Type:Organization
Organization Name:DENTAL ASSOSIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-808-3031
Mailing Address - Street 1:545 E JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-2856
Mailing Address - Country:US
Mailing Address - Phone:920-924-9090
Mailing Address - Fax:
Practice Address - Street 1:545 E JOHNSON ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2856
Practice Address - Country:US
Practice Address - Phone:920-924-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental