Provider Demographics
NPI:1568522720
Name:THE FUN KIDS DENTIST, S.C.
Entity Type:Organization
Organization Name:THE FUN KIDS DENTIST, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:TROCHLELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-786-1270
Mailing Address - Street 1:16655 BLUEMOUND RD
Mailing Address - Street 2:SUITE 380
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005
Mailing Address - Country:US
Mailing Address - Phone:262-786-1270
Mailing Address - Fax:262-786-0023
Practice Address - Street 1:16655 BLUEMOUND RD
Practice Address - Street 2:SUITE 380
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005
Practice Address - Country:US
Practice Address - Phone:262-786-1270
Practice Address - Fax:262-786-0023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001405122300000X
WI50011629122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty