Provider Demographics
NPI:1447315460
Name:KOLLATH, PAUL A (DDS)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:A
Last Name:KOLLATH
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 1:2805 LIBAL ST.
Mailing Address - Street 2:STE. C
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2877
Mailing Address - Country:US
Mailing Address - Phone:920-339-8980
Mailing Address - Fax:920-339-0133
Practice Address - Street 1:2805 LIBAL ST.
Practice Address - Street 2:STE. C
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2877
Practice Address - Country:US
Practice Address - Phone:920-339-8980
Practice Address - Fax:920-339-0133
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1857G122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33353100Medicaid