Provider Demographics
NPI:1225525959
Name:MEADOWBROOK SMILES
Entity Type:Organization
Organization Name:MEADOWBROOK SMILES
Other - Org Name:TIMBERCREEK SMILES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:P
Authorized Official - Last Name:VANMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-366-5068
Mailing Address - Street 1:2550 GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6849
Mailing Address - Country:US
Mailing Address - Phone:920-434-3900
Mailing Address - Fax:920-434-6980
Practice Address - Street 1:2550 GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6849
Practice Address - Country:US
Practice Address - Phone:920-434-3900
Practice Address - Fax:920-434-6980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15-5497261QD0000X
WI1001549-15261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental