Healthcare Provider Details

I. General information

NPI: 1376747493
Provider Name (Legal Business Name): POTH FAMILY DENTAL, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARTIN DR
FREDONIA WI
53021-9455
US

IV. Provider business mailing address

100 MARTIN DR
FREDONIA WI
53021-9455
US

V. Phone/Fax

Practice location:
  • Phone: 262-692-2461
  • Fax: 262-692-9889
Mailing address:
  • Phone: 262-692-2461
  • Fax: 262-692-9889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number4245-015
License Number StateWI

VIII. Authorized Official

Name: DR. JOHN EVERETT POTH
Title or Position: PRESIDENT
Credential: DDS
Phone: 262-692-2461