Basic Information
| Provider Information | |||||||||
| NPI: | 1588197149 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILIA DENTAL WEST GREEN BAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 E ALGONQUIN RD STE 610 | ||||||||
| Address2: | |||||||||
| City: | SCHAUMBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601734166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | 8474964850 | ||||||||
| Practice Location | |||||||||
| Address1: | 2280 W MASON ST | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543034707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889884066 | ||||||||
| FaxNumber: | 8474964850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2017 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | ALEXANDER | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING & PAYER RELATIONS MGR | ||||||||
| AuthorizedOfficialTelephone: | 8474537396 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPCS | ||||||||
| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.