Healthcare Provider Details

I. General information

NPI: 1104963784
Provider Name (Legal Business Name): MICHELLE NATALIE DACOSTA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 N DR MARTIN LUTHER KING DR MILWAUKEE HEALTH SERVICES INC
MILWAUKEE WI
53212-2709
US

IV. Provider business mailing address

2555 N DR MARTIN LUTHER KING DR MILWAUKEE HEALTH SERVICES INC
MILWAUKEE WI
53212-2709
US

V. Phone/Fax

Practice location:
  • Phone: 414-372-8080
  • Fax: 414-760-3983
Mailing address:
  • Phone: 414-372-8080
  • Fax: 414-760-3983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4727
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number4727
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: