MEDICARE: LABADIE FAMILY DENTISTRY, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	7064	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7064-15	OTHER	WI	DEPARTMENT OF REGULATION & LICENSES

General Provider Information

NPI Number	:	1356884613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LABADIE FAMILY DENTISTRY, S.C.

Provider Business Mailing Address
First Line	:	5019 MORMON RD.
Second Line	:
City	:	BURLINGTON
State	:	WI
Zip	:	53105
Country	:	US
Telephone Number	:	262-716-9239
Fax Number	:

Provider Business Practice Location Address
First Line	:	5019 MORMON RD.
Second Line	:
City	:	BURLINGTON
State	:	WI
Zip	:	53105
Country	:	US
Telephone Number	:	262-716-9239
Fax Number	:

Authorized Official
Title or Position	:	OWNER, DENTIST
Name	:	DR. EMILY LABADIE
Credential	:	D.D.S.
Telephone Number	:	262-716-9239

Provider Enumeration Date	:	11/18/2016
Last Update Date	:	11/18/2016

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