NPIMap

Organization Active NPI

Familia Dental Kenosha LLC

  • Dental Clinic/Center
  • Kenosha, WI
National Provider Identifier
1154782209
Registry record updated Jun 25, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dental Clinic/CenterTaxonomy code 261QD0000X
Legal business name
FAMILIA DENTAL KENOSHA LLC
Practice address
6430 Green Bay Rd.
Ste. 112
Kenosha, WI 53142-2948
Phone
(262) 653-3980
Fax
(262) 455-7710
NPI assigned
Mar 17, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 25, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Brandon Alexander Taylor, CPCS
Title
Credentialing & Payer Relations Man
Phone
(847) 453-7396

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X
Dental Clinic/Center 261QD0000X Primary

Addresses

Primary practice location

6430 Green Bay Rd.
Ste. 112
Kenosha, WI 53142-2948

Mailing address

2050 East Algonquin Road
Suite 610
Schaumburg, IL 60173-4166
Phone (847) 453-7396

National Provider Directory

National Provider Directory

Locations

6430 Green Bay Rd
Ste 112
Kenosha, WI 53142
Phone (262) 653-3980

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1458172800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1624579200000",
    "number": "1154782209",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2050 EAST ALGONQUIN ROAD",
            "address_2": "SUITE 610",
            "city": "SCHAUMBURG",
            "state": "IL",
            "postal_code": "601734166",
            "telephone_number": "847-453-7396",
            "fax_number": "847-453-7396"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6430 GREEN BAY RD.",
            "address_2": "STE. 112",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531422948",
            "telephone_number": "262-653-3980",
            "fax_number": "262-455-7710"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILIA DENTAL KENOSHA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-03-17",
        "last_updated": "2021-06-25",
        "certification_date": "2021-06-25",
        "status": "A",
        "authorized_official_last_name": "TAYLOR",
        "authorized_official_first_name": "BRANDON",
        "authorized_official_middle_name": "ALEXANDER",
        "authorized_official_title_or_position": "CREDENTIALING & PAYER RELATIONS MAN",
        "authorized_official_telephone_number": "847-453-7396",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CPCS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Kenosha, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.