Provider Demographics
NPI:1316081441
Name:WATERFORD FAMILY DENTAL LLC
Entity type:Organization
Organization Name:WATERFORD FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRITTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-534-5303
Mailing Address - Street 1:107A W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-4129
Mailing Address - Country:US
Mailing Address - Phone:262-534-5303
Mailing Address - Fax:262-514-4388
Practice Address - Street 1:107A W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-4129
Practice Address - Country:US
Practice Address - Phone:262-534-5303
Practice Address - Fax:262-514-4388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3199-015261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental