Provider Demographics
NPI:1861628133
Name:ADVANCED FAMILY DENTISTRY, S.C.
Entity Type:Organization
Organization Name:ADVANCED FAMILY DENTISTRY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-261-0588
Mailing Address - Street 1:123 HOSPITAL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3331
Mailing Address - Country:US
Mailing Address - Phone:920-261-0588
Mailing Address - Fax:920-261-0640
Practice Address - Street 1:123 HOSPITAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3331
Practice Address - Country:US
Practice Address - Phone:920-261-0588
Practice Address - Fax:920-261-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-01
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33741400Medicaid