Provider Demographics
NPI: | 1841746450 |
---|---|
Name: | BOSCOBEL FAMILY DENTAL, LLC |
Entity Type: | Organization |
Organization Name: | BOSCOBEL FAMILY DENTAL, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OFFICE MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ANGELA |
Authorized Official - Middle Name: | K |
Authorized Official - Last Name: | SALMON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 608-647-3222 |
Mailing Address - Street 1: | 105 E BLUFF ST |
Mailing Address - Street 2: | |
Mailing Address - City: | BOSCOBEL |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 53805-1610 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 608-375-4549 |
Mailing Address - Fax: | 608-375-4665 |
Practice Address - Street 1: | 105 E. BLUFF STREET |
Practice Address - Street 2: | |
Practice Address - City: | BOSCOBEL |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53805 |
Practice Address - Country: | US |
Practice Address - Phone: | 608-375-4549 |
Practice Address - Fax: | 608-375-4665 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-09-01 |
Last Update Date: | 2016-09-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WI | 1001394 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |