MEDICARE: MRS. IANTHA SHANAA MCWAY RDH

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	124Q00000X	Dental Hygienist	1003069-16	WI

General Provider Information

NPI Number	:	1902377922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IANTHA SHANAA MCWAY RDH

Provider Business Mailing Address
First Line	:	5754 N 72ND ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-2227
Country	:	US
Telephone Number	:	262-422-8753
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 W BROWN DEER RD STE A
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-1220
Country	:	US
Telephone Number	:	262-422-8753
Fax Number	:

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

Provider Enumeration Date	:	12/17/2018
Last Update Date	:	12/17/2018

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