Provider Demographics
NPI:1114453024
Name:MUNOZ, JUAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:
Last Name:MUNOZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JUAN
Other - Middle Name:
Other - Last Name:MUNOZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:410 SECURITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-9705
Mailing Address - Country:US
Mailing Address - Phone:920-662-1440
Mailing Address - Fax:
Practice Address - Street 1:410 SECURITY BLVD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-9705
Practice Address - Country:US
Practice Address - Phone:920-662-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI1001621-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program