=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902377922
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IANTHA SHANAA MCWAY RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2018
-----------------------------------------------------
Last Update Date | 12/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 W BROWN DEER RD STE A
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53209-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-422-8753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5754 N 72ND ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53218-2227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-422-8753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 1003069-16
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------