Healthcare Provider Details

I. General information

NPI: 1578946265
Provider Name (Legal Business Name): DUSTIN HETKE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1357 2ND AVE
CUMBERLAND WI
54829-7211
US

IV. Provider business mailing address

1357 2ND AVE
CUMBERLAND WI
54829-7211
US

V. Phone/Fax

Practice location:
  • Phone: 715-822-2091
  • Fax: 715-802-0336
Mailing address:
  • Phone: 715-822-2091
  • Fax: 715-802-0336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3386-35
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: