Healthcare Provider Details

I. General information

NPI: 1265513741
Provider Name (Legal Business Name): CRAIG EDWARD MAHLUM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W10237 LAKE EMILY ROAD
FOX LAKE WI
53933
US

IV. Provider business mailing address

W322N6811 WILDWOOD POINT RD
HARTLAND WI
53029-9711
US

V. Phone/Fax

Practice location:
  • Phone: 262-470-8646
  • Fax:
Mailing address:
  • Phone: 920-928-6949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2959
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: