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General NPI Number Information
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NPI Number | 1164109336
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Entity Type | Individual
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Provider Name | DR. TARIQ ELMADAWY
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Gender | Male
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Dates
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Enumeration Date | 06/29/2023
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Last Update Date | 01/27/2025
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Provider Practice Location Address
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Address Line | 1551 PARK PL STE 300
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City | GREEN BAY
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State | WI
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Zip | 54304-1969
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Country | US
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Telephone | 920-332-6644
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Fax |
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Provider Business Mailing Address
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Address Line | 2480 MARINA CIR UNIT 502
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City | ASHWAUBENON
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State | WI
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Zip | 54304-4877
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Country | US
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Telephone | 734-502-8196
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6001237-15
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901601681
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License Number State | MI
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