Provider Demographics
NPI:1851433114
Name:EVERGREEN DENTAL, SC
Entity Type:Organization
Organization Name:EVERGREEN DENTAL, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:POPELKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-734-0601
Mailing Address - Street 1:2310 E EVERGREEN DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7404
Mailing Address - Country:US
Mailing Address - Phone:920-734-0601
Mailing Address - Fax:920-734-9159
Practice Address - Street 1:2310 E EVERGREEN DR
Practice Address - Street 2:SUITE A
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7404
Practice Address - Country:US
Practice Address - Phone:920-734-0601
Practice Address - Fax:920-734-9159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3400W1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty