Provider Demographics
NPI:1184959405
Name:MONROE STREET FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:MONROE STREET FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FARROW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-204-0222
Mailing Address - Street 1:2702 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-1888
Mailing Address - Country:US
Mailing Address - Phone:608-204-0222
Mailing Address - Fax:608-240-0224
Practice Address - Street 1:2702 MONROE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1888
Practice Address - Country:US
Practice Address - Phone:608-204-0222
Practice Address - Fax:608-240-0224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-04
Last Update Date:2009-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5964-015261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental