Healthcare Provider Details

I. General information

NPI: 1740635424
Provider Name (Legal Business Name): JERI MCCOMBS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5709 ODANA RD
MADISON WI
53719
US

IV. Provider business mailing address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

V. Phone/Fax

Practice location:
  • Phone: 608-274-5970
  • Fax:
Mailing address:
  • Phone: 773-975-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1001584
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: