Healthcare Provider Details

I. General information

NPI: 1083705495
Provider Name (Legal Business Name): BAYLAKES CENTER FOR COMPLEX DENTISTRY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 SIEGLER ST
GREEN BAY WI
54303
US

IV. Provider business mailing address

138 SIEGLER ST
GREEN BAY WI
54303
US

V. Phone/Fax

Practice location:
  • Phone: 920-499-9958
  • Fax: 920-499-1492
Mailing address:
  • Phone: 920-499-9958
  • Fax: 920-499-1492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901015553
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901015553
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5001473015
License Number StateWI

VIII. Authorized Official

Name: DR. JOSEPH WILLIAM LASNOSKI
Title or Position: PRESIDENT PROSTHODONTIST
Credential: DDS MS
Phone: 920-499-9958