| Organization Name: | POTH FAMILY DENTAL, S.C. |
| NPI Number: | 1376747493 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JOHN EVERETT POTH (PRESIDENT) |
| Mailing Address: | 100 Martin Dr Fredonia |
| State: | WI US |
| Postal Code: | 530219455 |
| Phone Number: | 2626922461 |
| Fax Number: | 2626929889 |
| NPI Enumeration Date: | 06/13/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | 4245-015 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |