Provider Demographics
NPI:1922477793
Name:CRESTVIEW FAMILY DENTAL
Entity Type:Organization
Organization Name:CRESTVIEW FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MATHYS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-250-0701
Mailing Address - Street 1:1810 CREST VIEW DR
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-9494
Mailing Address - Country:US
Mailing Address - Phone:715-386-3727
Mailing Address - Fax:
Practice Address - Street 1:1810 CREST VIEW DR
Practice Address - Street 2:SUITE 5A
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9494
Practice Address - Country:US
Practice Address - Phone:715-386-3727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6410-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty