Provider Demographics
NPI:1790442838
Name:GREEN BAY DENTAL PROFESSIONALS LLC
Entity Type:Organization
Organization Name:GREEN BAY DENTAL PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:MITCH
Authorized Official - Middle Name:
Authorized Official - Last Name:WEILAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-343-0818
Mailing Address - Street 1:8025 EXCELSIOR DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1900
Mailing Address - Country:US
Mailing Address - Phone:608-343-0818
Mailing Address - Fax:
Practice Address - Street 1:1551 PARK PL STE 300
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1969
Practice Address - Country:US
Practice Address - Phone:920-345-5150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty