=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184987489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENOR FAMILY DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2012
-----------------------------------------------------
Last Update Date | 07/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 CONGRESS AVE
-----------------------------------------------------
City | OSHKOSH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54901-7701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-233-0400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 N RICHMOND ST
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54911-1956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-860-9252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | REBECCA L BERGENE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-860-9252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------