MEDICARE: THERESA GARDOCKI DENTIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	3054	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801987631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA GARDOCKI DENTIS

Provider Business Mailing Address
First Line	:	600 PLEASANT OAK DR
Second Line	:
City	:	OREGON
State	:	WI
Zip	:	53575-3648
Country	:	US
Telephone Number	:	608-835-3388
Fax Number	:	608-835-3386

Provider Business Practice Location Address
First Line	:	600 PLEASANT OAK DR
Second Line	:
City	:	OREGON
State	:	WI
Zip	:	53575-3648
Country	:	US
Telephone Number	:	608-835-3388
Fax Number	:	608-835-3386

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	01/26/2009

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Directions to “ THERESA GARDOCKI DENTIS” Practice Location

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