Healthcare Provider Details

I. General information

NPI: 1144298266
Provider Name (Legal Business Name): TIMOTHY R MIELKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N MAYFAIR RD SUITE 750
WAUWATOSA WI
53226-1309
US

IV. Provider business mailing address

534 CRESCENT CT
WAUWATOSA WI
53213-3856
US

V. Phone/Fax

Practice location:
  • Phone: 414-257-3366
  • Fax: 414-258-1390
Mailing address:
  • Phone: 414-257-3585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5001477015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: