=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760728166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINNECONNE FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2012
-----------------------------------------------------
Last Update Date | 12/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 902 E MAIN ST
-----------------------------------------------------
City | WINNECONNE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54986-9782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-582-4427
-----------------------------------------------------
Fax | 920-582-7563
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4668 W WOODLAND DR
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53132-8014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RYAN JOSEPH GONZALEZ
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 414-202-9184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5471
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------