Provider Demographics
NPI:1801367545
Name:FENNIMORE DENTAL, LLC
Entity Type:Organization
Organization Name:FENNIMORE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ZHENYU
Authorized Official - Middle Name:
Authorized Official - Last Name:LIANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-822-3770
Mailing Address - Street 1:220 LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:FENNIMORE
Mailing Address - State:WI
Mailing Address - Zip Code:53809
Mailing Address - Country:US
Mailing Address - Phone:608-822-3770
Mailing Address - Fax:608-822-7680
Practice Address - Street 1:220 LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:FENNIMORE
Practice Address - State:WI
Practice Address - Zip Code:53809
Practice Address - Country:US
Practice Address - Phone:608-822-3770
Practice Address - Fax:608-822-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03359042Medicaid