Provider First Line Business Practice Location Address:
1801 W WISCONSIN AVE
Provider Second Line Business Practice Location Address:
DENTAL SCHOOL, ROOM 364
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53233-2186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-288-2142
Provider Business Practice Location Address Fax Number:
414-288-1468
Provider Enumeration Date:
07/17/2013