Provider Demographics
NPI:1881290872
Name:UNION GROVE FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:UNION GROVE FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LENZ GALBREATH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:262-930-8297
Mailing Address - Street 1:1680 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-1525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1680 15TH AVE
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-1525
Practice Address - Country:US
Practice Address - Phone:262-878-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental