Provider Demographics
NPI:1275792772
Name:MLNARIK, JAMIE LYNN
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:MLNARIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 ALLOUEZ AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6267
Mailing Address - Country:US
Mailing Address - Phone:920-465-4902
Mailing Address - Fax:
Practice Address - Street 1:1595 ALLOUEZ AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6267
Practice Address - Country:US
Practice Address - Phone:920-465-4902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice