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General NPI Number Information
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NPI Number | 1184959405
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Entity Type | Organization
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Legal Business Name | MONROE STREET FAMILY DENTAL, LLC
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Dates
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Enumeration Date | 10/04/2009
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Last Update Date | 10/04/2009
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Provider Practice Location Address
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Address Line | 2702 MONROE ST
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City | MADISON
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State | WI
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Zip | 53711-1888
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Country | US
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Telephone | 608-204-0222
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Fax | 608-240-0224
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Provider Business Mailing Address
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Address Line | 2702 MONROE ST
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City | MADISON
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State | WI
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Zip | 53711-1888
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Country | US
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Telephone | 608-204-0222
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Fax | 608-240-0224
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Authorized Official
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Title or Position | MEMBER
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Name | BENJAMIN JOSEPH FARROW
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Credential | D.D.S
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Telephone | 608-204-0222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 5964-015
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License Number State | WI
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