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General NPI Number Information
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NPI Number | 1306117031
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Entity Type | Organization
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Legal Business Name | BAYCARE CLINIC LLP
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Dates
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Enumeration Date | 01/26/2012
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Last Update Date | 04/13/2022
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Provider Practice Location Address
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Address Line | 920 E 5TH ST
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City | SHAWANO
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State | WI
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Zip | 54166-2212
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Country | US
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Telephone | 715-524-2001
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Fax | 715-524-6267
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Provider Business Mailing Address
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Address Line | PO BOX 28900
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City | GREEN BAY
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State | WI
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Zip | 54324-0900
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Country | US
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Telephone | 920-490-9046
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Fax | 920-405-5384
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Authorized Official
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Title or Position | SENIOR PROVIDER CREDENTIALING COORD
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Name | NICOLE HETTMANN
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Credential |
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Telephone | 920-490-9046
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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