Healthcare Provider Details

I. General information

NPI: 1366848509
Provider Name (Legal Business Name): SEUBERT FAMILY DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 W. COOK ST.
PORTAGE WI
53901-2106
US

IV. Provider business mailing address

260 W. COOK ST.
PORTAGE WI
53901-2106
US

V. Phone/Fax

Practice location:
  • Phone: 608-742-2331
  • Fax: 608-742-4308
Mailing address:
  • Phone: 608-742-2331
  • Fax: 608-742-4308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3967
License Number StateWI

VIII. Authorized Official

Name: MR. JAN LLOYD SEUBERT
Title or Position: DR./DENTIST
Credential: DDS
Phone: 608-742-2331