Healthcare Provider Details

I. General information

NPI: 1457965485
Provider Name (Legal Business Name): MICHELLE WU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N GAMMON RD STE 1
MIDDLETON WI
53562-3874
US

IV. Provider business mailing address

4013 DEVONSHIRE ST
STERLING HEIGHTS MI
48310-3842
US

V. Phone/Fax

Practice location:
  • Phone: 608-831-5151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019032878
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901601516
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6001146-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: