Healthcare Provider Details

I. General information

NPI: 1023565686
Provider Name (Legal Business Name): BELLE CITY FAMILY DENTISTRY, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S GREEN BAY RD SUITE 206
RACINE WI
53406
US

IV. Provider business mailing address

1300 S GREEN BAY RD SUITE 206
RACINE WI
53406
US

V. Phone/Fax

Practice location:
  • Phone: 262-633-4000
  • Fax:
Mailing address:
  • Phone: 262-633-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5001949-015
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7238-15
License Number StateWI

VIII. Authorized Official

Name: DR. KIMBERLY OLESEN
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 262-497-5374