Provider Demographics
NPI:1235665464
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:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINEMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-733-4787
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-09
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001068G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty