Provider Demographics
NPI:1205905619
Name:CHILDREN'S DENTAL CLINIC OF GREEN BAY, S.C.
Entity type:Organization
Organization Name:CHILDREN'S DENTAL CLINIC OF GREEN BAY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-336-4002
Mailing Address - Street 1:534 REDBIRD CIR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-8785
Mailing Address - Country:US
Mailing Address - Phone:920-336-4002
Mailing Address - Fax:920-336-4112
Practice Address - Street 1:534 REDBIRD CIR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-8785
Practice Address - Country:US
Practice Address - Phone:920-336-4002
Practice Address - Fax:920-336-4112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty