Healthcare Provider Details

I. General information

NPI: 1710191085
Provider Name (Legal Business Name): LISA RACHEL PIONTEK D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 S MONROE AVE
GREEN BAY WI
54301-4018
US

IV. Provider business mailing address

2701 PARKWOOD DR
GREEN BAY WI
54304-1811
US

V. Phone/Fax

Practice location:
  • Phone: 920-448-7340
  • Fax:
Mailing address:
  • Phone: 920-499-1996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4647
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: