Healthcare Provider Details

I. General information

NPI: 1306058326
Provider Name (Legal Business Name): TIMOTHY J TIKALSKY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11407 W BLUEMOUND RD
WAUWATOSA WI
53226
US

IV. Provider business mailing address

11407 W BLUEMOUND RD
WAUWATOSA WI
53226
US

V. Phone/Fax

Practice location:
  • Phone: 414-258-0120
  • Fax: 414-259-9850
Mailing address:
  • Phone: 414-258-0120
  • Fax: 414-259-9850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6124015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: