Provider Demographics
NPI:1376618207
Name:ORTHODONTIC SPECIALISTS OF GREEN BAY, LTD
Entity Type:Organization
Organization Name:ORTHODONTIC SPECIALISTS OF GREEN BAY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:920-336-2299
Mailing Address - Street 1:1839 SCHEURING ROAD
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115
Mailing Address - Country:US
Mailing Address - Phone:920-336-2299
Mailing Address - Fax:
Practice Address - Street 1:1839 SCHEURING RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9401
Practice Address - Country:US
Practice Address - Phone:920-336-2299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty