Provider Demographics
NPI:1952460123
Name:REEDSBURG FAMILY DENTAL, S.C.
Entity Type:Organization
Organization Name:REEDSBURG FAMILY DENTAL, S.C.
Other - Org Name:KITSON AND SORENSON FAMILY DENTAL, S.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SORENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-524-4213
Mailing Address - Street 1:764 CRESTVIEW DR
Mailing Address - Street 2:P.O. BOX 383
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-2581
Mailing Address - Country:US
Mailing Address - Phone:608-524-4213
Mailing Address - Fax:608-524-0743
Practice Address - Street 1:764 CRESTVIEW DR
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-2581
Practice Address - Country:US
Practice Address - Phone:608-524-4213
Practice Address - Fax:608-524-0743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3386-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38381600Medicaid