Healthcare Provider Details

I. General information

NPI: 1871638254
Provider Name (Legal Business Name): ABC FAMILY DENTAL SERVICES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 04/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 CENTER DR
LUXEMBURG WI
54217-1031
US

IV. Provider business mailing address

613 CENTER DR
LUXEMBURG WI
54217-1031
US

V. Phone/Fax

Practice location:
  • Phone: 920-845-2225
  • Fax: 920-845-5627
Mailing address:
  • Phone: 920-845-2225
  • Fax: 920-845-5627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4930 AND 4892
License Number StateWI

VIII. Authorized Official

Name: DR. BRYAN WILLIAM IWEN
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 920-845-2225