Healthcare Provider Details

I. General information

NPI: 1881364958
Provider Name (Legal Business Name): CAMPFIRE PEDIATRIC DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8391 GREENWAY BLVD STE 100
MIDDLETON WI
53562-3544
US

IV. Provider business mailing address

8391 GREENWAY BLVD STE 100
MIDDLETON WI
53562-3544
US

V. Phone/Fax

Practice location:
  • Phone: 815-979-3837
  • Fax:
Mailing address:
  • Phone: 608-535-9382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NATHANAEL D BENASSI
Title or Position: MEMBER
Credential: DDS
Phone: 608-535-9382