Provider Demographics
NPI:1881364958
Name:CAMPFIRE PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:CAMPFIRE PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NATHANAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BENASSI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-535-9382
Mailing Address - Street 1:8391 GREENWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3544
Mailing Address - Country:US
Mailing Address - Phone:608-535-9382
Mailing Address - Fax:
Practice Address - Street 1:8391 GREENWAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3544
Practice Address - Country:US
Practice Address - Phone:815-979-3837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-20
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty