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General NPI Number Information
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NPI Number | 1609948967
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Entity Type | Organization
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Legal Business Name | THE FAMILY DENTISTS
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Dates
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Enumeration Date | 11/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1680 15TH AVE
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City | UNION GROVE
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State | WI
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Zip | 53182-1525
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Country | US
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Telephone | 262-878-1500
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Fax | 262-878-4782
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Provider Business Mailing Address
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Address Line | 1680 15TH AVE
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City | UNION GROVE
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State | WI
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Zip | 53182-1525
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Country | US
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Telephone | 262-878-1500
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Fax | 262-878-4782
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN R ULLOA
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Credential | D.M.D.
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Telephone | 262-878-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4398
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License Number State | WI
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