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General NPI Number Information
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NPI Number | 1881364958
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Entity Type | Organization
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Legal Business Name | CAMPFIRE PEDIATRIC DENTISTRY, LLC
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Dates
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Enumeration Date | 09/20/2021
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Last Update Date | 04/28/2022
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Provider Practice Location Address
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Address Line | 8391 GREENWAY BLVD STE 100
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City | MIDDLETON
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State | WI
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Zip | 53562-3544
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Country | US
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Telephone | 815-979-3837
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Fax |
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Provider Business Mailing Address
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Address Line | 8391 GREENWAY BLVD STE 100
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City | MIDDLETON
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State | WI
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Zip | 53562-3544
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Country | US
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Telephone | 608-535-9382
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | NATHANAEL D BENASSI
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Credential | DDS
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Telephone | 608-535-9382
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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