Healthcare Provider Details

I. General information

NPI: 1689265076
Provider Name (Legal Business Name): AMHERST FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 CHRISTY ST
AMHERST WI
54406-9389
US

IV. Provider business mailing address

172 CHRISTY ST
AMHERST WI
54406-9389
US

V. Phone/Fax

Practice location:
  • Phone: 715-824-3300
  • Fax:
Mailing address:
  • Phone: 715-824-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAYLA THORPE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 920-982-3567