Provider Demographics
NPI:1003460551
Name:AFFORDABLE DENTURES & IMPLANTS - GREEN BAY, S.C.
Entity Type:Organization
Organization Name:AFFORDABLE DENTURES & IMPLANTS - GREEN BAY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-499-7159
Mailing Address - Street 1:1800-C W. MASON STREET
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303
Mailing Address - Country:US
Mailing Address - Phone:920-499-7159
Mailing Address - Fax:
Practice Address - Street 1:1800-C W. MASON STREET
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303
Practice Address - Country:US
Practice Address - Phone:920-499-7159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty