Provider Demographics
NPI:1679819858
Name:WEBER DENTAL LLC
Entity type:Organization
Organization Name:WEBER DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHIAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-782-7120
Mailing Address - Street 1:17585 W NORTH AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4365
Mailing Address - Country:US
Mailing Address - Phone:262-782-7120
Mailing Address - Fax:262-782-0656
Practice Address - Street 1:17585 W NORTH AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4365
Practice Address - Country:US
Practice Address - Phone:262-782-7120
Practice Address - Fax:262-782-0656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4628-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty