Provider Demographics
NPI:1831760784
Name:ALLENTON FAMILY DENTISTRY
Entity type:Organization
Organization Name:ALLENTON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOLVER
Authorized Official - Middle Name:
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-762-5655
Mailing Address - Street 1:608 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTON
Mailing Address - State:WI
Mailing Address - Zip Code:53002-1014
Mailing Address - Country:US
Mailing Address - Phone:262-629-5595
Mailing Address - Fax:
Practice Address - Street 1:608 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ALLENTON
Practice Address - State:WI
Practice Address - Zip Code:53002-1014
Practice Address - Country:US
Practice Address - Phone:262-629-5955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental