Healthcare Provider Details

I. General information

NPI: 1295015444
Provider Name (Legal Business Name): JANSSEN DENTAL CLINIC S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2649 DEVELOPMENT DR
GREEN BAY WI
54311-4240
US

IV. Provider business mailing address

2649 DEVELOPMENT DR
GREEN BAY WI
54311-4240
US

V. Phone/Fax

Practice location:
  • Phone: 920-983-8383
  • Fax: 920-983-2862
Mailing address:
  • Phone: 920-983-8383
  • Fax: 920-983-2862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3485
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. CRAIG B JANSSEN
Title or Position: OWNER
Credential: DDS
Phone: 920-983-8383