Provider Demographics
NPI:1649337726
Name:WANEZEK FAMILY DENTISTRY
Entity type:Organization
Organization Name:WANEZEK FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:M
Authorized Official - Last Name:WANEZEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-642-5881
Mailing Address - Street 1:PO BOX 15
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120
Mailing Address - Country:US
Mailing Address - Phone:262-642-5881
Mailing Address - Fax:262-642-7252
Practice Address - Street 1:W3278 MAIN STREET
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120
Practice Address - Country:US
Practice Address - Phone:262-642-5881
Practice Address - Fax:262-642-7252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty