Provider Demographics
NPI:1669128260
Name:SHAWANO FAMILY DENTISTRY
Entity type:Organization
Organization Name:SHAWANO FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-865-7293
Mailing Address - Street 1:115 ALPINE CT
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2048
Mailing Address - Country:US
Mailing Address - Phone:715-524-4935
Mailing Address - Fax:
Practice Address - Street 1:115 ALPINE CT
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2048
Practice Address - Country:US
Practice Address - Phone:715-524-4935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty