Healthcare Provider Details

I. General information

NPI: 1841419587
Provider Name (Legal Business Name): NICOLAS ABUJAMRA DDS MS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2581 DEVELOPMENT DR SUITE 102
GREEN BAY WI
54311-4247
US

IV. Provider business mailing address

2581 DEVELOPMENT DR SUITE 102
GREEN BAY WI
54311-4247
US

V. Phone/Fax

Practice location:
  • Phone: 920-347-2626
  • Fax: 920-347-2621
Mailing address:
  • Phone: 920-347-2626
  • Fax: 920-347-2621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4873-015
License Number StateWI

VIII. Authorized Official

Name: DR. NICOLAS FAWZI ABUJAMRA
Title or Position: DOCTOR
Credential: DDS, MS
Phone: 920-347-2626