MEDICARE: GREENBAYCTD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1023699576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENBAYCTD LLC

Provider Business Mailing Address
First Line	:	8025 EXCELSIOR DR
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53717-1900
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2280 HOLMGREN WAY
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-4710
Country	:	US
Telephone Number	:	920-489-3491
Fax Number	:

Authorized Official
Title or Position	:	ASSISTANT CONTROLLER
Name	:	MITCH WEILAND
Credential	:
Telephone Number	:	608-343-0818

Provider Enumeration Date	:	04/16/2021
Last Update Date	:	04/16/2021

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