Provider Demographics
NPI:1083705495
Name:BAYLAKES CENTER FOR COMPLEX DENTISTRY SC
Entity Type:Organization
Organization Name:BAYLAKES CENTER FOR COMPLEX DENTISTRY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PROSTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LASNOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:920-499-9958
Mailing Address - Street 1:138 SIEGLER ST
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:920-499-9958
Mailing Address - Fax:920-499-1492
Practice Address - Street 1:138 SIEGLER ST
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:920-499-9958
Practice Address - Fax:920-499-1492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015553122300000X, 1223P0700X
WI50014730151223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty