Provider Demographics
NPI:1639246127
Name:FAMILY DENTAL CENTER, SC
Entity Type:Organization
Organization Name:FAMILY DENTAL CENTER, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:SEIDL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-684-8033
Mailing Address - Street 1:3712 KADOW ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-5450
Mailing Address - Country:US
Mailing Address - Phone:920-684-8033
Mailing Address - Fax:920-684-6360
Practice Address - Street 1:3712 KADOW ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5450
Practice Address - Country:US
Practice Address - Phone:920-684-8033
Practice Address - Fax:920-684-6360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3890122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38393000Medicaid