Healthcare Provider Details

I. General information

NPI: 1073368254
Provider Name (Legal Business Name): CAMPBELLSPORT FAMILY DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2024
Last Update Date: 04/20/2024
Certification Date: 04/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 N FOND DU LAC AVE
CAMPBELLSPORT WI
53010-2787
US

IV. Provider business mailing address

130 N FOND DU LAC AVE
CAMPBELLSPORT WI
53010-2787
US

V. Phone/Fax

Practice location:
  • Phone: 920-533-8512
  • Fax:
Mailing address:
  • Phone:
  • 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: DANIEL STEVENS
Title or Position: OWNER
Credential: DDS
Phone: 608-957-4663