Provider Demographics
NPI:1881307882
Name:EBY FAMILY DENTAL OF JEFFERSON
Entity type:Organization
Organization Name:EBY FAMILY DENTAL OF JEFFERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RENDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-563-2928
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-0299
Mailing Address - Country:US
Mailing Address - Phone:920-563-2928
Mailing Address - Fax:920-897-6081
Practice Address - Street 1:1491 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-2931
Practice Address - Country:US
Practice Address - Phone:920-563-2928
Practice Address - Fax:920-897-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-04
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental