Healthcare Provider Details

I. General information

NPI: 1407313521
Provider Name (Legal Business Name): JONATHAN HANNA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE # MS 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-2040
  • Fax: 414-266-5677
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1001933
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: