Healthcare Provider Details

I. General information

NPI: 1871161653
Provider Name (Legal Business Name): JIGEESHA MOPIDEVI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N14W23833 STONE RIDGE DR
WAUKESHA WI
53188-1157
US

IV. Provider business mailing address

405 BISHOPS WAY UNIT 438
BROOKFIELD WI
53005-6255
US

V. Phone/Fax

Practice location:
  • Phone: 262-357-2040
  • Fax:
Mailing address:
  • Phone: 510-579-6264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1002573
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: