Provider Demographics
NPI:1487939948
Name:WOJTAK, TERESA (DH)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:WOJTAK
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 22ND ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 57TH ST
Practice Address - Street 2:SUITE 700
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4146
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9643-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist