Provider Demographics
NPI:1275668964
Name:NABAK, MARY LOU (RDH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOU
Last Name:NABAK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:LOU
Other - Last Name:CYR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:1343 GLEN RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5609
Mailing Address - Country:US
Mailing Address - Phone:920-497-0232
Mailing Address - Fax:920-494-8195
Practice Address - Street 1:1711 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3215
Practice Address - Country:US
Practice Address - Phone:920-494-9541
Practice Address - Fax:920-494-2026
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2919016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist