Provider Demographics
NPI:1396468476
Name:FOX VALLEY DENTAL CENTER
Entity type:Organization
Organization Name:FOX VALLEY DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:LEAH
Authorized Official - Last Name:HAREID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-307-6025
Mailing Address - Street 1:315 KRAFT ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-4988
Mailing Address - Country:US
Mailing Address - Phone:415-307-6025
Mailing Address - Fax:
Practice Address - Street 1:760 W NORTHLAND AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1425
Practice Address - Country:US
Practice Address - Phone:920-731-7717
Practice Address - Fax:920-733-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1972751923OtherINDIVIDUAL NPI