Healthcare Provider Details

I. General information

NPI: 1164550208
Provider Name (Legal Business Name): EBBEN & PYNENBERG DDS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 WILSON ST
LITTLE CHUTE WI
54140
US

IV. Provider business mailing address

607 WILSON ST
LITTLE CHUTE WI
54140
US

V. Phone/Fax

Practice location:
  • Phone: 920-788-3542
  • Fax: 920-788-6741
Mailing address:
  • Phone: 920-788-3542
  • Fax: 920-788-6741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4142
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2739
License Number StateWI

VIII. Authorized Official

Name: MICHAEL CHARLES EBBEN
Title or Position: PRESIDENT
Credential: DDS
Phone: 920-788-3542