Provider Demographics
NPI:1609039122
Name:RICHLAND FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:RICHLAND FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-647-3222
Mailing Address - Street 1:1313 W SEMINARY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-2067
Mailing Address - Country:US
Mailing Address - Phone:608-649-3222
Mailing Address - Fax:
Practice Address - Street 1:1313 W SEMINARY ST STE 200
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-2067
Practice Address - Country:US
Practice Address - Phone:608-649-3222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6287-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty