Provider Demographics
NPI:1851844161
Name:GREEN BAY FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:GREEN BAY FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:EGGERS-ULVE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:920-432-2961
Mailing Address - Street 1:2609 DEVELOPMENT DR.
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311
Mailing Address - Country:US
Mailing Address - Phone:920-432-2961
Mailing Address - Fax:
Practice Address - Street 1:2609 DEVELOPMENT DR.
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311
Practice Address - Country:US
Practice Address - Phone:920-432-2961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty