Provider Demographics
NPI:1821131210
Name:FAMILY DENTISTRY OF WEST SALEM, INC.
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF WEST SALEM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FORSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-786-1632
Mailing Address - Street 1:210 N LEONARD ST
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-1623
Mailing Address - Country:US
Mailing Address - Phone:608-786-1632
Mailing Address - Fax:608-786-0225
Practice Address - Street 1:210 N LEONARD ST
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-1623
Practice Address - Country:US
Practice Address - Phone:608-786-1632
Practice Address - Fax:608-786-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33441300Medicaid