Provider Demographics
NPI:1154045953
Name:BLUE SKIES PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:BLUE SKIES PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:PRIEVE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:608-960-8414
Mailing Address - Street 1:220 KEENAN CT STE 100
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-9720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 KEENAN COURT
Practice Address - Street 2:SUITE #100
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593
Practice Address - Country:US
Practice Address - Phone:608-960-8414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-27
Last Update Date:2023-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental