Provider Demographics
NPI:1477639102
Name:ALLOUEZ FAMILY DENTAL CENTER SC
Entity type:Organization
Organization Name:ALLOUEZ FAMILY DENTAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOLLATH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-339-8980
Mailing Address - Street 1:2805 LIBAL ST
Mailing Address - Street 2:STE C
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2877
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:920-339-0133
Practice Address - Street 1:2805 LIBAL ST
Practice Address - Street 2:STE C
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2788
Practice Address - Country:US
Practice Address - Phone:920-339-8980
Practice Address - Fax:920-339-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1857-G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========Medicare UPIN