Healthcare Provider Details

I. General information

NPI: 1174500813
Provider Name (Legal Business Name): VILLAGE FAMILY DENTAL ASSCOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 MILLS ST
BLACK EARTH WI
53515-9420
US

IV. Provider business mailing address

1209 MILLS ST
BLACK EARTH WI
53515-9420
US

V. Phone/Fax

Practice location:
  • Phone: 608-767-3604
  • Fax: 608-767-3606
Mailing address:
  • Phone: 608-767-3604
  • Fax: 608-767-3606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL F PEEPLES
Title or Position: PRESIDENT OF CORPORATION
Credential: DDS
Phone: 608-643-8505