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General NPI Number Information
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NPI Number | 1366840456
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Entity Type | Organization
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Legal Business Name | NORTH LAKE FAMILY DENTISTRY
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Dates
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Enumeration Date | 12/05/2014
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Last Update Date | 12/05/2014
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Provider Practice Location Address
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Address Line | W315N7641 HWY 83
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City | HARTLAND
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State | WI
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Zip | 53029-9759
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Country | US
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Telephone | 262-966-7668
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Fax |
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Provider Business Mailing Address
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Address Line | W315N7641 HWY 83
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City | HARTLAND
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State | WI
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Zip | 53029-9759
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Country | US
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Telephone | 262-966-7668
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. PATTY R ERICKSON
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Credential | DDS
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Telephone | 262-966-7668
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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 | 6346
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License Number State | WI
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