Provider Demographics
NPI:1104911239
Name:IGWIKE, EMMANUEL (DDS)
Entity type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:
Last Name:IGWIKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 W BRADLEY RD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1700
Mailing Address - Country:US
Mailing Address - Phone:414-371-2506
Mailing Address - Fax:
Practice Address - Street 1:4141 W BRADLEY RD
Practice Address - Street 2:SUITE 214
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209-1700
Practice Address - Country:US
Practice Address - Phone:414-371-2506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33778800Medicaid