Provider Demographics
NPI:1184793580
Name:GENERATIONS FAMILY DENTAL
Entity type:Organization
Organization Name:GENERATIONS FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:A
Authorized Official - Last Name:LACOURT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-258-2117
Mailing Address - Street 1:2505 N MAYFAIR RD
Mailing Address - Street 2:#103
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-258-2117
Mailing Address - Fax:414-258-4177
Practice Address - Street 1:2505 N MAYFAIR RD
Practice Address - Street 2:#103
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-258-2117
Practice Address - Fax:414-258-4177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3547WI1223G0001X
WI50013391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
690859OtherUNITED CONCORDIA
98924OtherUNITED CONCORDIA