MEDICARE: DR. MARISA OLIVIA LOW DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1002105-15	WI

General Provider Information

NPI Number	:	1750941522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARISA OLIVIA LOW DDS

Provider Business Mailing Address
First Line	:	1833 UNIVERSITY AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54302-3637
Country	:	US
Telephone Number	:	760-579-2787
Fax Number	:

Provider Business Practice Location Address
First Line	:	1833 UNIVERSITY AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54302-3637
Country	:	US
Telephone Number	:	920-437-7444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2019
Last Update Date	:	06/14/2019

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