Provider Demographics
NPI:1588197149
Name:FAMILIA DENTAL WEST GREEN BAY
Entity Type:Organization
Organization Name:FAMILIA DENTAL WEST GREEN BAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & PAYER RELATIONS MGR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:847-453-7396
Mailing Address - Street 1:2050 E ALGONQUIN RD STE 610
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4166
Mailing Address - Country:US
Mailing Address - Phone:888-988-4066
Mailing Address - Fax:847-496-4850
Practice Address - Street 1:2280 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4707
Practice Address - Country:US
Practice Address - Phone:888-988-4066
Practice Address - Fax:847-496-4850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
WI10010441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty