Healthcare Provider Details

I. General information

NPI: 1477344406
Provider Name (Legal Business Name): SOFIA GRACE DACQUISTO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2025
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3522 W LISBON AVE
MILWAUKEE WI
53208-1953
US

IV. Provider business mailing address

4615 W WOODWARD DR
FRANKLIN WI
53132-7610
US

V. Phone/Fax

Practice location:
  • Phone: 414-935-8000
  • Fax: 414-344-3350
Mailing address:
  • Phone: 414-813-3152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6001846
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: