=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255566295
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEROME A MAHALICK DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2009
-----------------------------------------------------
Last Update Date | 05/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 E SILVER SPRING DR SUITE 3
-----------------------------------------------------
City | WHITEFISH BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53217-5210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-332-1011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 EAST SILVER SPRING DRIVE SUITE 3
-----------------------------------------------------
City | WHITEFISH BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-332-1011
-----------------------------------------------------
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 | 5000323-015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------