Provider Demographics
NPI:1104916576
Name:SMULLEN, GEORGE H (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:H
Last Name:SMULLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8281 WAHL LANE
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154
Mailing Address - Country:US
Mailing Address - Phone:920-848-5551
Mailing Address - Fax:
Practice Address - Street 1:2733 MANITOWOC RD
Practice Address - Street 2:SUITE 2
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4901
Practice Address - Country:US
Practice Address - Phone:920-288-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50011931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33604100Medicaid