Provider Demographics
NPI:1215264270
Name:JANKE, THERESA MARY (RDH)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MARY
Last Name:JANKE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 BAYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4129
Mailing Address - Country:US
Mailing Address - Phone:920-261-8049
Mailing Address - Fax:
Practice Address - Street 1:1077 BAYBERRY DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4129
Practice Address - Country:US
Practice Address - Phone:920-261-8049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2820-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist