Healthcare Provider Details

I. General information

NPI: 1568488641
Provider Name (Legal Business Name): JAMES MICHAEL PODNAR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

11711 W BURLEIGH ST
WAUWATOSA WI
53222-3108
US

IV. Provider business mailing address

907 RIVER RESERVE DR
HARTLAND WI
53029-2913
US

V. Phone/Fax

Practice location:
  • Phone: 414-777-3817
  • Fax: 414-771-7640
Mailing address:
  • Phone: 262-367-3619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4866-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: