Provider Demographics
NPI:1699236240
Name:OSHKOSH FAMILY DENTAL LLC
Entity type:Organization
Organization Name:OSHKOSH FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-215-5899
Mailing Address - Street 1:8025 EXCELSIOR DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1900
Mailing Address - Country:US
Mailing Address - Phone:608-833-2213
Mailing Address - Fax:
Practice Address - Street 1:1815 W POINTE DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-4174
Practice Address - Country:US
Practice Address - Phone:608-833-2213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHERRY TREE DENTAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty