Provider Demographics
NPI:1205900586
Name:GENEVA FAMILY DENTISTRY
Entity type:Organization
Organization Name:GENEVA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTACT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GENIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-450-0157
Mailing Address - Street 1:851 PARK DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-4586
Mailing Address - Country:US
Mailing Address - Phone:262-248-4991
Mailing Address - Fax:262-248-0397
Practice Address - Street 1:851 PARK DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4586
Practice Address - Country:US
Practice Address - Phone:262-248-4991
Practice Address - Fax:262-248-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty