Provider Demographics
NPI:1740392000
Name:FEIDER, TIBORIS & BISTAN DDS SC
Entity Type:Organization
Organization Name:FEIDER, TIBORIS & BISTAN DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GINNY
Authorized Official - Middle Name:
Authorized Official - Last Name:FENNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-457-2255
Mailing Address - Street 1:1630 N TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1929
Mailing Address - Country:US
Mailing Address - Phone:920-457-2255
Mailing Address - Fax:920-458-0469
Practice Address - Street 1:1630 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1929
Practice Address - Country:US
Practice Address - Phone:920-457-2255
Practice Address - Fax:920-458-0469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty