Basic Information
Provider Information | |||||||||
NPI: | 1699138297 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILIA DENTAL MADISON WEST LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2050 E ALGONQUIN RD | ||||||||
Address2: | SUITE 610 | ||||||||
City: | SCHAUMBURG | ||||||||
State: | IL | ||||||||
PostalCode: | 601734144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8474537396 | ||||||||
FaxNumber: | 8474537396 | ||||||||
Practice Location | |||||||||
Address1: | 706 S GAMMON RD | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537191302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8889884066 | ||||||||
FaxNumber: | 8474964850 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2016 | ||||||||
LastUpdateDate: | 10/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAYLOR | ||||||||
AuthorizedOfficialFirstName: | BRANDON | ||||||||
AuthorizedOfficialMiddleName: | ALEXANDER | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING & PAYER RELATIONS MGR | ||||||||
AuthorizedOfficialTelephone: | 8474537396 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
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.