Provider Demographics
NPI:1609592534
Name:KEYSTONE BAYVIEW LLC
Entity Type:Organization
Organization Name:KEYSTONE BAYVIEW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:POTRYKUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-873-0510
Mailing Address - Street 1:PO BOX 180163
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-0163
Mailing Address - Country:US
Mailing Address - Phone:262-873-0510
Mailing Address - Fax:
Practice Address - Street 1:3380 S KINNICKINNIC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-3159
Practice Address - Country:US
Practice Address - Phone:262-873-0510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental