Provider Demographics
NPI:1932949203
Name:DEDERICH, DOUGLAS NORMAN (DDS, PHD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:NORMAN
Last Name:DEDERICH
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 W GREENFIELD AVE APT 408
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-5073
Mailing Address - Country:US
Mailing Address - Phone:780-868-1562
Mailing Address - Fax:
Practice Address - Street 1:500 W SILVER SPRING DR STE K250
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5062
Practice Address - Country:US
Practice Address - Phone:414-963-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-25
Last Update Date:2024-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3322-151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty