Provider Demographics
NPI:1851750442
Name:LAKE MILLS FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:LAKE MILLS FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:H
Authorized Official - Last Name:BOYSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:608-213-1667
Mailing Address - Street 1:140 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1659
Mailing Address - Country:US
Mailing Address - Phone:920-648-8254
Mailing Address - Fax:920-648-3655
Practice Address - Street 1:140 E LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1659
Practice Address - Country:US
Practice Address - Phone:920-648-8254
Practice Address - Fax:920-648-3655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental