Provider Demographics
NPI:1578666798
Name:HOM FAMILY DENTISTRY., S.C.
Entity type:Organization
Organization Name:HOM FAMILY DENTISTRY., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAE
Authorized Official - Last Name:HOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-341-1212
Mailing Address - Street 1:2925 POST RD
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-6455
Mailing Address - Country:US
Mailing Address - Phone:715-341-1212
Mailing Address - Fax:715-341-5943
Practice Address - Street 1:2925 POST RD
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-6455
Practice Address - Country:US
Practice Address - Phone:715-341-1212
Practice Address - Fax:715-341-0470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33391400Medicaid