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General NPI Number Information
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NPI Number | 1205905619
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Entity Type | Organization
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Legal Business Name | CHILDREN'S DENTAL CLINIC OF GREEN BAY, S.C.
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 01/07/2011
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Provider Practice Location Address
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Address Line | 534 REDBIRD CIR
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City | DE PERE
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State | WI
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Zip | 54115-8785
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Country | US
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Telephone | 920-336-4002
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Fax | 920-336-4112
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Provider Business Mailing Address
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Address Line | 534 REDBIRD CIR
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City | DE PERE
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State | WI
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Zip | 54115-8785
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Country | US
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Telephone | 920-336-4002
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Fax | 920-336-4112
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. MARGARET ANN MILLER
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Credential | DDS
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Telephone | 920-336-4002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 4176
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License Number State | WI
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