=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093373623
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLOR LEANN DUMEZ DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2019
-----------------------------------------------------
Last Update Date | 05/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11501 N PORT WASHINGTON RD STE 102
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-3466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-241-8880
-----------------------------------------------------
Fax | 262-241-5250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 N BROADWAY APT 205
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53202-5940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-980-6453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1002030-15
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------