Healthcare Provider Details

I. General information

NPI: 1891174967
Provider Name (Legal Business Name): BELGIUM FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 MAIN ST
BELGIUM WI
53004-9715
US

IV. Provider business mailing address

171 MAIN ST
BELGIUM WI
53004-9715
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 TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number1001078-15
License Number StateWI

VIII. Authorized Official

Name: DR. VALI KIAIE
Title or Position: DOCTOR/OWNER
Credential: D.D.S.
Phone: 262-285-3408