MEDICARE: MADELYN RAE ZASTROW

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	7865	NE
2	1223G0001X	General Practice Dentistry	6001064-15	WI
3	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1891437877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELYN RAE ZASTROW

Provider Business Mailing Address
First Line	:	6185 OVERLOOK CT
Second Line	:
City	:	GREENDALE
State	:	WI
Zip	:	53129-2135
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6070 N PORT WASHINGTON RD
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53217-4524
Country	:	US
Telephone Number	:	414-928-7076
Fax Number	:

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

Provider Enumeration Date	:	04/11/2022
Last Update Date	:	02/17/2026

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