Provider Demographics
NPI:1740628254
Name:LAYTON DENTAL LAB
Entity type:Organization
Organization Name:LAYTON DENTAL LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-691-7100
Mailing Address - Street 1:495 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3537
Mailing Address - Country:US
Mailing Address - Phone:262-691-7100
Mailing Address - Fax:
Practice Address - Street 1:495 HICKORY ST
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3537
Practice Address - Country:US
Practice Address - Phone:262-691-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory