Healthcare Provider Details

I. General information

NPI: 1124900907
Provider Name (Legal Business Name): WEST PRAIRIE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 IRONWOOD DR
SUN PRAIRIE WI
53590-8830
US

IV. Provider business mailing address

2630 IRONWOOD DR
SUN PRAIRIE WI
53590-8830
US

V. Phone/Fax

Practice location:
  • Phone: 608-837-7842
  • Fax: 608-318-8787
Mailing address:
  • Phone: 608-837-7842
  • Fax: 608-318-8787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: KELSEY LAUFENBERG
Title or Position: OFFICE MANAGER
Credential:
Phone: 608-837-7842