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General NPI Number Information
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NPI Number | 1023565686
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Entity Type | Organization
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Legal Business Name | BELLE CITY FAMILY DENTISTRY, S.C.
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Dates
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Enumeration Date | 09/01/2016
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Last Update Date | 09/01/2016
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Provider Practice Location Address
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Address Line | 1300 S GREEN BAY RD SUITE 206
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City | RACINE
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State | WI
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Zip | 53406
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Country | US
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Telephone | 262-633-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 1300 S GREEN BAY RD SUITE 206
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City | RACINE
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State | WI
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Zip | 53406
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Country | US
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Telephone | 262-633-4000
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KIMBERLY OLESEN
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Credential | D.D.S.
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Telephone | 262-497-5374
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 5001949-015
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7238-15
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License Number State | WI
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