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General NPI Number Information
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NPI Number | 1356489603
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Entity Type | Organization
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Legal Business Name | EAST TOWNE DENTAL ASSOCIATED BELGIUM FAMILY DENTAL SC
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 11501 N PROT WASHINGTON RD
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City | MEQUON
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State | WI
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Zip | 53092
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Country | US
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Telephone | 262-241-8880
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Fax | 262-241-5250
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Provider Business Mailing Address
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Address Line | 11501 N PROT WASHINGTON RD
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City | MEQUON
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State | WI
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Zip | 53092
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Country | US
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Telephone | 262-241-8880
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Fax | 262-241-5250
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Authorized Official
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Title or Position | PRESIDENT
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Name | VALI KIAIE
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Credential | DDS
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Telephone | 262-241-8880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5301
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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 | 5304
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5993
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License Number State | WI
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