Provider Demographics
NPI:1376626325
Name:MEDICAL ARTS COMPLEX DENTAL CENTER, S.C.
Entity Type:Organization
Organization Name:MEDICAL ARTS COMPLEX DENTAL CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:NOBLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-435-6894
Mailing Address - Street 1:704 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3528
Mailing Address - Country:US
Mailing Address - Phone:920-435-6894
Mailing Address - Fax:920-435-7676
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-435-6894
Practice Address - Fax:920-435-7676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33571900Medicaid
WI33738400Medicaid
WI33777700Medicaid
WI33461900Medicaid
WI33759300Medicaid
WI33734500Medicaid