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General NPI Number Information
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NPI Number | 1861927535
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Entity Type | Organization
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Legal Business Name | VISTA FAMILY DENTISTRY, LLC
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Dates
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Enumeration Date | 05/01/2017
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Last Update Date | 05/01/2017
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Provider Practice Location Address
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Address Line | 20855 WATERTOWN RD SUITE 120
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City | WAUKESHA
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State | WI
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Zip | 53186-1860
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Country | US
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Telephone | 262-717-9104
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Fax | 262-717-9105
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Provider Business Mailing Address
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Address Line | 20855 WATERTOWN RD SUITE 120
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City | WAUKESHA
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State | WI
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Zip | 53186-1860
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Country | US
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Telephone | 262-717-9104
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Fax | 262-717-9105
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Authorized Official
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Title or Position | DENTIST/PRESIDENT
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Name | DR. VASSILIS K PANAGOPOULOS
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Credential | D.D.S.
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Telephone | 262-717-9104
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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 | 6265-15
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License Number State | WI
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