Healthcare Provider Details

I. General information

NPI: 1982092995
Provider Name (Legal Business Name): ANDRIOLA MALAVECI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2014
Last Update Date: 01/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4302 N 76TH ST
MILWAUKEE WI
53222-2004
US

IV. Provider business mailing address

4302 N 76TH ST
MILWAUKEE WI
53222-2004
US

V. Phone/Fax

Practice location:
  • Phone: 414-462-9420
  • Fax:
Mailing address:
  • Phone: 414-462-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number100251116
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: