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General NPI Number Information
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NPI Number | 1417298696
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Entity Type | Organization
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Legal Business Name | LITTLE SPROUTS DENTAL, LLC
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Dates
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Enumeration Date | 03/13/2013
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Last Update Date | 03/13/2013
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Provider Practice Location Address
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Address Line | W62N563 WASHINGTON AVE LOWER LEVEL
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City | CEDARBURG
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State | WI
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Zip | 53012-1986
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Country | US
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Telephone | 262-297-0079
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Fax |
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Provider Business Mailing Address
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Address Line | W62N563 WASHINGTON AVE LOWER LEVEL
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City | CEDARBURG
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State | WI
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Zip | 53012-1986
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Country | US
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Telephone | 262-297-0079
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. MATTHEW H. LANGEWISCH
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Credential | D.D.S.
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Telephone | 262-297-0079
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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 | 5824-15
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License Number State | WI
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