Provider Demographics
NPI:1104297571
Name:WICKMAN, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54138-0179
Mailing Address - Country:US
Mailing Address - Phone:715-276-6321
Mailing Address - Fax:715-276-1428
Practice Address - Street 1:15397 STATE HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WI
Practice Address - Zip Code:54138-9702
Practice Address - Country:US
Practice Address - Phone:715-276-6321
Practice Address - Fax:715-276-1428
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002641124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist