Healthcare Provider Details

I. General information

NPI: 1245649250
Provider Name (Legal Business Name): THOMAS JAHNKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20350 WATER TOWER BLVD STE 10
BROOKFIELD WI
53045-3558
US

IV. Provider business mailing address

2817 REILLY ST
FORT BRAGG NC
28310-7324
US

V. Phone/Fax

Practice location:
  • Phone: 262-327-6100
  • Fax:
Mailing address:
  • Phone: 910-643-2196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9789
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: