Provider Demographics
NPI:1871638254
Name:ABC FAMILY DENTAL SERVICES, S.C.
Entity Type:Organization
Organization Name:ABC FAMILY DENTAL SERVICES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:IWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-845-2225
Mailing Address - Street 1:613 CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LUXEMBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54217-1031
Mailing Address - Country:US
Mailing Address - Phone:920-845-2225
Mailing Address - Fax:920-845-5627
Practice Address - Street 1:613 CENTER DR
Practice Address - Street 2:
Practice Address - City:LUXEMBURG
Practice Address - State:WI
Practice Address - Zip Code:54217-1031
Practice Address - Country:US
Practice Address - Phone:920-845-2225
Practice Address - Fax:920-845-5627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4930 AND 48921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33740400Medicaid
WI33744300Medicaid