Healthcare Provider Details

I. General information

NPI: 1396001483
Provider Name (Legal Business Name): CHAD RANDALL SEUBERT D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3164 FINGER RD
GREEN BAY WI
54311-7602
US

IV. Provider business mailing address

3164 FINGER RD
GREEN BAY WI
54311-7602
US

V. Phone/Fax

Practice location:
  • Phone: 920-471-0022
  • Fax: 920-471-0755
Mailing address:
  • Phone: 920-471-0022
  • Fax: 920-471-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number362
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1001261
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: