Provider Demographics
NPI:1578322897
Name:DAVIS FAMILY DENTAL, SC
Entity Type:Organization
Organization Name:DAVIS FAMILY DENTAL, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-310-1860
Mailing Address - Street 1:N161W20685 KAMI LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037-8937
Mailing Address - Country:US
Mailing Address - Phone:262-622-1571
Mailing Address - Fax:
Practice Address - Street 1:1201 OAK ST STE D
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3800
Practice Address - Country:US
Practice Address - Phone:262-310-1860
Practice Address - Fax:262-310-1861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty