Provider Demographics
NPI:1700131935
Name:HIGHLAND PARK FAMILY DENTISTRY, SC
Entity Type:Organization
Organization Name:HIGHLAND PARK FAMILY DENTISTRY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-475-9035
Mailing Address - Street 1:6101 W VLIET ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2485
Mailing Address - Country:US
Mailing Address - Phone:414-475-9035
Mailing Address - Fax:414-475-9039
Practice Address - Street 1:6101 W VLIET ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2485
Practice Address - Country:US
Practice Address - Phone:414-475-9035
Practice Address - Fax:414-475-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4097261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental