Vande Walle, Mark Robert

Vande Walle, Mark Robert is an individual health care provider with primary practice located at 1711 Shawano Ave , Green Bay WI 54303. He recently has only one registered license in Dental Providers / Dentist, which is considered as his primary health care specialty. Vande Walle, Mark Robert can be contacted via phone (920) 494-9541.

Contact Information

Primary practice address
1711 Shawano Ave Green Bay WI 54303
Phone: (920) 494-9541
Fax:
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Dental Providers / Dentist 122300000X 003209 Wisconsin

Profile Details

NPI number 1083749774
LBN Legal business name Vande Walle, Mark Robert
Credentials Doctor of Dental Surgery (DDS)
Entity Individual
Sole proprietor 1 No
Enumeration date Feb 22nd, 2007
Last updated Jul 8th, 2007 - about 17 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1083749774 NPPES
Wisconsin MEDICAID 33456900

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