Healthcare Provider Details

I. General information

NPI: 1417764986
Provider Name (Legal Business Name): JEANETTE PAHL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 S 18TH AVE
STURGEON BAY WI
54235-1000
US

IV. Provider business mailing address

5616 W CARLSVILLE RD
STURGEON BAY WI
54235-9741
US

V. Phone/Fax

Practice location:
  • Phone: 920-746-3788
  • Fax: 920-743-3340
Mailing address:
  • Phone: 920-419-1924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number11605-16
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: