Provider Demographics
NPI:1154890549
Name:NEW LONDON FAMILY DENTAL LLC
Entity type:Organization
Organization Name:NEW LONDON FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:THORPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-982-3567
Mailing Address - Street 1:105 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2703
Mailing Address - Country:US
Mailing Address - Phone:920-982-3567
Mailing Address - Fax:
Practice Address - Street 1:105 NORTH RIDGE DR
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-5496
Practice Address - Country:US
Practice Address - Phone:920-982-3567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========Medicaid