Provider Demographics
NPI:1174726194
Name:FAMILY DENTISTRY
Entity type:Organization
Organization Name:FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:RAJEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-536-2282
Mailing Address - Street 1:301 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-2317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 E 2ND ST
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-2317
Practice Address - Country:US
Practice Address - Phone:715-539-3211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAN W. RAJEK, DDS, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-07
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50021391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1861438897OtherNPI- TYPE 1
WI5002139OtherLISCENSE NUMBER (WI)