Provider Demographics
NPI:1962596395
Name:MOLLICK, SHEPPARD B (DMD)
Entity type:Individual
Prefix:
First Name:SHEPPARD
Middle Name:B
Last Name:MOLLICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10535 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5583
Mailing Address - Country:US
Mailing Address - Phone:414-241-0900
Mailing Address - Fax:414-241-0904
Practice Address - Street 1:10535 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5583
Practice Address - Country:US
Practice Address - Phone:414-241-0900
Practice Address - Fax:414-241-0904
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI5001300-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery