Provider Demographics
NPI:1982143574
Name:MOSINEE FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:MOSINEE FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-693-4530
Mailing Address - Street 1:435 ORBITING DR STE A
Mailing Address - Street 2:
Mailing Address - City:MOSINEE
Mailing Address - State:WI
Mailing Address - Zip Code:54455-1762
Mailing Address - Country:US
Mailing Address - Phone:715-693-4530
Mailing Address - Fax:
Practice Address - Street 1:435 ORBITING DR STE A
Practice Address - Street 2:
Practice Address - City:MOSINEE
Practice Address - State:WI
Practice Address - Zip Code:54455-1762
Practice Address - Country:US
Practice Address - Phone:715-693-4530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5542-15122300000X
WI5001639-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty