Provider Demographics
NPI:1609948967
Name:THE FAMILY DENTISTS
Entity Type:Organization
Organization Name:THE FAMILY DENTISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ULLOA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:262-878-1500
Mailing Address - Street 1:1680 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-1525
Mailing Address - Country:US
Mailing Address - Phone:262-878-1500
Mailing Address - Fax:262-878-4782
Practice Address - Street 1:1680 15TH AVE
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-1525
Practice Address - Country:US
Practice Address - Phone:262-878-1500
Practice Address - Fax:262-878-4782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty