Healthcare Provider Details

I. General information

NPI: 1164560165
Provider Name (Legal Business Name): EAST TOWNE DENTAL ASSOCIATES BELGIUM FAMILY DENTAL SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 MAIN ST SUITE 200
BELGIUM WI
53004
US

IV. Provider business mailing address

PO BOX 147
BELGIUM WI
53004
US

V. Phone/Fax

Practice location:
  • Phone: 262-285-3408
  • Fax: 262-285-4025
Mailing address:
  • Phone: 262-285-3408
  • Fax: 262-285-4025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5301
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5993
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5304
License Number StateWI

VIII. Authorized Official

Name: VALI KIAIE
Title or Position: PRESIDENT
Credential: DDS
Phone: 262-285-3408