Healthcare Provider Details

I. General information

NPI: 1164536967
Provider Name (Legal Business Name): DOWNTOWN FAMILY DENTAL OF BARABOO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 3RD ST
BARABOO WI
53913-2423
US

IV. Provider business mailing address

147 3RD ST
BARABOO WI
53913-2423
US

V. Phone/Fax

Practice location:
  • Phone: 608-356-3790
  • Fax: 608-356-7863
Mailing address:
  • Phone: 608-356-3790
  • Fax: 608-356-7863

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: TONI M HOLLOWAY
Title or Position: OFFICE MANAGER
Credential:
Phone: 608-356-3790