MEDICARE: WINNECONNE FAMILY DENTISTRY

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	5471	WI

General Provider Information

NPI Number	:	1760728166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WINNECONNE FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	4668 W WOODLAND DR
Second Line	:
City	:	FRANKLIN
State	:	WI
Zip	:	53132-8014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	902 E MAIN ST
Second Line	:
City	:	WINNECONNE
State	:	WI
Zip	:	54986-9782
Country	:	US
Telephone Number	:	920-582-4427
Fax Number	:	920-582-7563

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RYAN JOSEPH GONZALEZ
Credential	:	D.D.S
Telephone Number	:	414-202-9184

Provider Enumeration Date	:	12/13/2012
Last Update Date	:	12/13/2012

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