MEDICARE: GENERATIONS FAMILY DENTAL CARE-RANDOM LAKE, LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1407387483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENERATIONS FAMILY DENTAL CARE-RANDOM LAKE, LLC

Provider Business Mailing Address
First Line	:	2505 N MAYFAIR RD
Second Line	:	SUITE 103
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-1404
Country	:	US
Telephone Number	:	414-258-2117
Fax Number	:

Provider Business Practice Location Address
First Line	:	37 HICKORY DR
Second Line	:
City	:	RANDOM LAKE
State	:	WI
Zip	:	53075-1675
Country	:	US
Telephone Number	:	920-994-4367
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. FRED LACOURT
Credential	:	DDS, FAGD
Telephone Number	:	414-258-2117

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	03/22/2017

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