MEDICARE: JORDAN BOEHLKE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6001482-15	WI

General Provider Information

NPI Number	:	1770322026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN BOEHLKE

Provider Business Mailing Address
First Line	:	1700 CORAL DR
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53186-1483
Country	:	US
Telephone Number	:	262-650-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 CORAL DR
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53186-1483
Country	:	US
Telephone Number	:	262-650-3000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2024
Last Update Date	:	01/24/2025

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Directions to “ JORDAN BOEHLKE ” Practice Location

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