Provider Demographics
NPI:1285778969
Name:BLACK RIVER FAMILY DENTISTRY LTD
Entity type:Organization
Organization Name:BLACK RIVER FAMILY DENTISTRY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:HERZBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-284-3100
Mailing Address - Street 1:N6625 COUNTY HWY A
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615
Mailing Address - Country:US
Mailing Address - Phone:715-284-3100
Mailing Address - Fax:715-284-8115
Practice Address - Street 1:N6625 COUNTY HWY A
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615
Practice Address - Country:US
Practice Address - Phone:715-284-3100
Practice Address - Fax:715-284-8115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIS149015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty