Healthcare Provider Details

I. General information

NPI: 1578508099
Provider Name (Legal Business Name): MARGARET A EBBOTT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 S CESAR E CHAVEZ DR
MILWAUKEE WI
53204-2266
US

IV. Provider business mailing address

9323 W ORCHARD ST
WEST ALLIS WI
53214-4161
US

V. Phone/Fax

Practice location:
  • Phone: 414-645-4540
  • Fax:
Mailing address:
  • Phone: 414-840-5697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3874-016
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: