Healthcare Provider Details

I. General information

NPI: 1750443347
Provider Name (Legal Business Name): WAYNE EDWARD WITTE DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 N 76 ST
MILWAUKEE WI
53213-3554
US

IV. Provider business mailing address

224 N 76 ST
MILWAUKEE WI
53213-3554
US

V. Phone/Fax

Practice location:
  • Phone: 414-476-6750
  • Fax:
Mailing address:
  • Phone: 414-476-6750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4001655015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: