MEDICARE: DR. JONATHAN JERRY KLICKA D.D.S.

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	1223G0001X	General Practice Dentistry	0002953	WI

General Provider Information

NPI Number	:	1922159300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN JERRY KLICKA D.D.S.

Provider Business Mailing Address
First Line	:	324 E WISCONSIN AVE STE 1429
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-4327
Country	:	US
Telephone Number	:	414-276-3454
Fax Number	:

Provider Business Practice Location Address
First Line	:	324 E WISCONSIN AVE STE 1429
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-4327
Country	:	US
Telephone Number	:	414-276-3454
Fax Number	:

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

Provider Enumeration Date	:	01/14/2007
Last Update Date	:	07/08/2007

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