Individual
MASON P WISTENBERG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3071 VOYAGER DR STE B, GREEN BAY, WI 54311-8352
(920) 465-9887
Mailing address
481 SAINT MARYS BLVD, GREEN BAY, WI 54301-2607
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
1002699-15
WI
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
02/24/2021
Last updated
08/15/2022
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