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General NPI Number Information
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NPI Number | 1184793580
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Entity Type | Organization
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Legal Business Name | GENERATIONS FAMILY DENTAL
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 06/22/2015
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Provider Practice Location Address
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Address Line | 2505 N MAYFAIR RD #103
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City | WAUWATOSA
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State | WI
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Zip | 53226
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Country | US
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Telephone | 414-258-2117
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Fax | 414-258-4177
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Provider Business Mailing Address
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Address Line | 2505 N MAYFAIR RD #103
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City | WAUWATOSA
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State | WI
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Zip | 53226
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Country | US
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Telephone | 414-258-2117
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Fax | 414-258-4177
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Authorized Official
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Title or Position | DENTIST
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Name | DR. FRED A LACOURT
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Credential | DDS
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Telephone | 414-258-2117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3547WI
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License Number State | WI
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