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NPI Code Detail

MEDICARE: GREEN BAY DENTAL PROFESSIONALS LLC

MEDICARE: GREEN BAY DENTAL PROFESSIONALS 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
1122300000XDentist

General Provider Information

NPI Number : 1790442838
Entity Type Code : Organization
Provider Name (Legal Business Name) : GREEN BAY DENTAL PROFESSIONALS LLC
Provider Business Mailing Address
First Line : 8025 EXCELSIOR DR
Second Line :
City : MADISON
State : WI
Zip : 53717-1900
Country : US
Telephone Number : 608-343-0818
Fax Number :
Provider Business Practice Location Address
First Line : 1551 PARK PL STE 300
Second Line :
City : GREEN BAY
State : WI
Zip : 54304-1969
Country : US
Telephone Number : 920-345-5150
Fax Number :
Authorized Official
Title or Position : ASSISTANT CONTROLLER
Name : MITCH WEILAND
Credential :
Telephone Number : 608-343-0818
Provider Enumeration Date : 11/23/2021
Last Update Date : 11/23/2021

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Directions to “GREEN BAY DENTAL PROFESSIONALS LLC ” Practice Location

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