Healthcare Provider Details

I. General information

NPI: 1902890445
Provider Name (Legal Business Name): GREGORY JACOB TULACHKA D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 CLAY ST
DARLINGTON WI
53530-1228
US

IV. Provider business mailing address

119 NINA DR
DARLINGTON WI
53530-1607
US

V. Phone/Fax

Practice location:
  • Phone: 608-776-4471
  • Fax: 608-776-4311
Mailing address:
  • Phone: 608-776-4650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number3145-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: