Provider Demographics
NPI:1962883926
Name:FAMILIA DENTAL RACINE LLC
Entity type:Organization
Organization Name:FAMILIA DENTAL RACINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & PAYER RELATIONS MAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:847-453-7396
Mailing Address - Street 1:2050 EAST ALGONQUIN ROAD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4166
Mailing Address - Country:US
Mailing Address - Phone:847-453-7396
Mailing Address - Fax:847-453-7396
Practice Address - Street 1:5201 WASHINGTON AVE
Practice Address - Street 2:STE A
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4242
Practice Address - Country:US
Practice Address - Phone:262-634-0441
Practice Address - Fax:262-583-4198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty