=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437341799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARY KAEFER FAMILY DENTISTY DDS SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2007
-----------------------------------------------------
Last Update Date | 08/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7425 MAIN ST W
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54893-8207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-866-4204
-----------------------------------------------------
Fax | 715-866-4205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7425 MAIN ST W PO BOX 4
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54893-8207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-866-4204
-----------------------------------------------------
Fax | 715-866-4205
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER- DENTIST
-----------------------------------------------------
Name | DR. GARY L KAEFER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 715-866-4204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 5001913
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------