Healthcare Provider Details

I. General information

NPI: 1902394570
Provider Name (Legal Business Name): MICHAEL DENTICE PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2018
Last Update Date: 04/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 W BURLEIGH ST
MILWAUKEE WI
53222-3211
US

IV. Provider business mailing address

N111W16153 CATSKILL LN
GERMANTOWN WI
53022-4072
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-0910
  • Fax:
Mailing address:
  • Phone: 262-327-6018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number19175-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: