Provider Demographics
NPI:1164549754
Name:OAK GROVE DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:OAK GROVE DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:GREATENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-468-6371
Mailing Address - Street 1:1640 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-2639
Mailing Address - Country:US
Mailing Address - Phone:920-468-6371
Mailing Address - Fax:920-468-6365
Practice Address - Street 1:1640 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-2639
Practice Address - Country:US
Practice Address - Phone:920-468-6371
Practice Address - Fax:920-468-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty