Provider Demographics
NPI:1053430991
Name:ASSOCIATED FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:ASSOCIATED FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:TOMCHEK
Authorized Official - Last Name:SARAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-922-7012
Mailing Address - Street 1:845 S MAIN ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-6174
Mailing Address - Country:US
Mailing Address - Phone:920-922-7012
Mailing Address - Fax:920-921-7101
Practice Address - Street 1:845 S MAIN ST
Practice Address - Street 2:SUITE 130
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6174
Practice Address - Country:US
Practice Address - Phone:920-922-7012
Practice Address - Fax:920-921-7101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4618-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty