Provider Demographics
NPI:1720198898
Name:BAY DENTAL ASSOCIATES OF GREEN BAY, INC.
Entity Type:Organization
Organization Name:BAY DENTAL ASSOCIATES OF GREEN BAY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:NOCKERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-469-8484
Mailing Address - Street 1:2460 FINGER RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-4210
Mailing Address - Country:US
Mailing Address - Phone:920-469-8484
Mailing Address - Fax:920-469-8486
Practice Address - Street 1:2460 FINGER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-4210
Practice Address - Country:US
Practice Address - Phone:920-469-8484
Practice Address - Fax:920-469-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38361000Medicaid