Provider Demographics
NPI:1558001180
Name:ADVANCED DENTAL SPECIALISTS, LLC
Entity Type:Organization
Organization Name:ADVANCED DENTAL SPECIALISTS, LLC
Other - Org Name:ADVANCED DENTAL SPECIALISTS GREEN BAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:2476 S ONEIDA ST STE 150
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5292
Mailing Address - Country:US
Mailing Address - Phone:920-954-8085
Mailing Address - Fax:920-954-9080
Practice Address - Street 1:2476 S ONEIDA ST STE 150
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5292
Practice Address - Country:US
Practice Address - Phone:920-954-8085
Practice Address - Fax:920-954-9080
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DENTAL SPECIALISTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-31
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty