Provider First Line Business Practice Location Address:
9000 W WISCONSIN AVE
Provider Second Line Business Practice Location Address:
MAIL STATION 773-DENTAL CLINIC
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-4874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-266-2040
Provider Business Practice Location Address Fax Number:
414-266-5677
Provider Enumeration Date:
10/24/2005