1104916576 NPI number — DR. GEORGE H SMULLEN DDS

Table of content: DR. GEORGE H SMULLEN DDS (NPI 1104916576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104916576 NPI number — DR. GEORGE H SMULLEN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMULLEN
Provider First Name:
GEORGE
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104916576
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8281 WAHL LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCONTO FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-848-5551
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2733 MANITOWOC RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54311-4901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-288-0200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5001193 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 33604100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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