Healthcare Provider Details

I. General information

NPI: 1447875711
Provider Name (Legal Business Name): IOLA FAMILY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PINE CREST LN
IOLA WI
54945-8230
US

IV. Provider business mailing address

100 PINE CREST LN
IOLA WI
54945-8230
US

V. Phone/Fax

Practice location:
  • Phone: 715-445-2435
  • 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: KAYLA THORPE
Title or Position: OFFICE MANAGER
Credential:
Phone: 920-982-3567