Healthcare Provider Details

I. General information

NPI: 1164355061
Provider Name (Legal Business Name): EVERBREEZE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4333 NAKOMA RD
MADISON WI
53711-3700
US

IV. Provider business mailing address

4324 PADDINGTON DR
CEDAR FALLS IA
50613-8917
US

V. Phone/Fax

Practice location:
  • Phone: 712-297-4560
  • Fax:
Mailing address:
  • Phone: 712-297-4560
  • 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: SAMUEL KIM
Title or Position: DENTIST
Credential: DDS
Phone: 712-297-4560