Healthcare Provider Details

I. General information

NPI: 1669814455
Provider Name (Legal Business Name): CHRISTABELLE E BRAAKSMA D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTABELLE MITCHELL

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 S PARK ST
MADISON WI
53713-1916
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-443-5482
  • Fax: 608-443-5534
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019029549
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1001037
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: