Provider Demographics
NPI:1467528760
Name:PARK PLACE DENTAL CARE
Entity Type:Organization
Organization Name:PARK PLACE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTACT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GENIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-450-0157
Mailing Address - Street 1:1551 PARK PL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1982
Mailing Address - Country:US
Mailing Address - Phone:920-497-8500
Mailing Address - Fax:920-497-3213
Practice Address - Street 1:1551 PARK PL
Practice Address - Street 2:SUITE 300
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1982
Practice Address - Country:US
Practice Address - Phone:920-497-8500
Practice Address - Fax:920-497-3213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty