Healthcare Provider Details

I. General information

NPI: 1174992937
Provider Name (Legal Business Name): MAURY FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 S MARR ST
FOND DU LAC WI
54935-4408
US

IV. Provider business mailing address

145 S MARR ST
FOND DU LAC WI
54935-4408
US

V. Phone/Fax

Practice location:
  • Phone: 920-921-6260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5369015
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number5369015
License Number StateWI

VIII. Authorized Official

Name: CHRIS MAURY
Title or Position: OWNER
Credential:
Phone: 920-921-6260