Provider Demographics
NPI:1891174967
Name:BELGIUM FAMILY DENTAL
Entity type:Organization
Organization Name:BELGIUM FAMILY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VALI
Authorized Official - Middle Name:
Authorized Official - Last Name:KIAIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-285-3408
Mailing Address - Street 1:171 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELGIUM
Mailing Address - State:WI
Mailing Address - Zip Code:53004-9715
Mailing Address - Country:US
Mailing Address - Phone:262-285-3408
Mailing Address - Fax:262-285-4025
Practice Address - Street 1:171 MAIN ST
Practice Address - Street 2:
Practice Address - City:BELGIUM
Practice Address - State:WI
Practice Address - Zip Code:53004-9715
Practice Address - Country:US
Practice Address - Phone:262-285-3408
Practice Address - Fax:262-285-4025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001078-15305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization