Provider Demographics
NPI:1700453719
Name:ELKHORN FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:ELKHORN FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GENIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:KUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-450-0157
Mailing Address - Street 1:1525 FAIRWAY LN
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-5000
Mailing Address - Country:US
Mailing Address - Phone:262-723-3296
Mailing Address - Fax:262-723-2556
Practice Address - Street 1:1525 FAIRWAY LN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-5000
Practice Address - Country:US
Practice Address - Phone:262-723-3296
Practice Address - Fax:262-723-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty