Provider Demographics
NPI:1881755692
Name:DOWNTOWN FAMILY DENTAL OF WEST BEND, INC
Entity type:Organization
Organization Name:DOWNTOWN FAMILY DENTAL OF WEST BEND, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:T
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-338-1164
Mailing Address - Street 1:309 N 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-3242
Mailing Address - Country:US
Mailing Address - Phone:262-338-1164
Mailing Address - Fax:262-338-1646
Practice Address - Street 1:309 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3242
Practice Address - Country:US
Practice Address - Phone:262-338-1164
Practice Address - Fax:262-338-1646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty